INTRAOPERATIVE PHASE OF SURGERY

Definition
The intraoperative phase extends from the time the client is admitted to
the operating room, to the time of anesthesia administration, performance of
the surgical procedure and until the client is transported to the recovery
room or post-anesthesia care unit (PACU).
Throughout the surgical experience the nurse functions as the patients chief
advocate. The nurses care and concern extend from the time the patient is
prepared for and instructed about the forthcoming surgical procedure to the
immediate preoperative period and into the operative phase and recovery
from anesthesia. The patient needs the security of knowing that someone is
providing protection during the procedure and while he is anesthetized
because surgery is usually a stressful experience.
Goals
1. Promote the principle of asepsis.
2. Homeostasis
3. Safe administration of anesthesia
4. Hemostasis
The Surgical Team
The intraoperative phase begins when the patient is received in the surgical
area and lasts until the patient is transferred to the recovery area. Although
the surgeon has the most important role in this phase, there are key
members of the surgical team.
1. Surgeon leader of the surgical team. He or she is ultimately
responsible for performing the surgery effectively and safely; however,
he is dependent upon other members of the team for the patients
emotional well-being and physiologic monitoring.
2. Anesthesiologist or anesthetist provides smooth induction of the
patients anesthesia in order to prevent pain. This member is also
responsible for maintaining satisfactory degrees of relaxation of the
patient for the duration of the surgical procedure. Aside from that, the
anesthesiologist continually monitors the physiologic status of the
patient for the duration of the surgical procedure and the physiologic

status of the patient to include oxygen exchange, systemic circulation,

neurologic status, and vital signs. He or she then informs and advises
the surgeon of impending complications.
3. Scrub Nurse or Assistant a nurse or surgical technician who
prepares the surgical set-up, maintains surgical asepsis while draping
and handling instruments, and assists the surgeon by passing
instruments, sutures, and supplies.
4. Circulating Nurse respond to request from the surgeon,
anesthesiologist or anesthetist, obtain supplies, deliver supplies to the
sterile field, and carry out the nursing care plan.
Nursing Functions
Circulating Nurse
The circulating nurse manages the operating room and protects the safety
and health needs of the patient by monitoring activities of members of the
surgical team and checking the conditions in the operating room.
Responsibilities of a circulation nurse are the following:
1. Assures cleanliness in the OR.
2. Guarantees the proper room temperature, humidity and lighting in OR.
3. Make certain that equipments are safely functioning.
4. Ensure that supplies and materials are available for use during surgical
procedures.
5. Monitors aseptic technique while coordinating the movement of related
personnel.
6. Monitors the patient throughout the operative procedure to ensure the
persons safety and well-being.
Scrub Nurse
The scrub nurse assists the surgeon during the whole procedure by
anticipating the required instruments and setting up the sterile table. The
responsibilities of the scrub nurse are:
1. Scrubbing for surgery.
2. Setting up sterile tables.

3. Preparing sutures and special equipments.

4. Assists the surgeon and assistant during the surgical procedure by
anticipating the required instruments, sponges, drains and other
equipment.
5. Keeps track of the time the patient is under anesthesia and the time
the wound is open.
6. Checks equipments and materials such as needles, sponges and
instruments as the surgical incision is closed.
Classification of Physical Status for Anesthesia before Surgery
The anesthesiologist should visit the patient before the surgery to provide
information, answer questions and allay fears that may exist in the patients
mind.
The choice of anesthetic agent will be discussed and the patient has an
opportunity to disclose and the patient has opportunity to disclose previous
reactions and information about any medication currently being taken that
may affect the choice of an agent. Aside from that, the patients general
condition must also be assessed because it may affect the management of
anesthesia. Thus, the anesthesiologist assesses the patients cardiovascular
system and lungs.
Inquiry about preexisting pulmonary infection sand the extent to which the
patient smokes must also be determined. The classification of a clients
physical status for anesthesia before surgery is summarized below.
Classification of Physical Status for Anesthesia Before Surgery
Classification
Description
Example
Good
No organic disease; no
Uncomplicated hernias,
systemic disturbance
fracture
Fair
Mild to moderate
Mild cardiac (I and II)
systemic disturbance
disease, mild diabetes
Poor
Severe systemic
Poorly controlled
disturbance
diabetes, pulmonary
complications, moderate
cardiac (III) disease
Serious
Systemic disease
Severe renal disease,
threatening life
severe cardiac disease
(IV), decompensation
Moribund
Little chance of survival Massive pulmonary

Emergency

but submitting to
embolus, ruptured
operation in desperation abdominal aneurysm with
profound shock
Any of the above when
An uncomplicated hernia
surgery is performed in
that is now strangulated
an emergency situation and associated with
nausea and vomiting.

Source: Brunner and Suddarths Medical-Surgical Nursing by Smeltzer and

Bare
Anesthesia
Anesthesia controls pain during surgery or other medical procedures. It
includes using medicines, and sometimes close monitoring, to keep you
comfortable. It can also help control breathing, blood pressure, blood flow,
and heart rate and rhythm, when needed. Anesthetics are divided into two
classes:
1. Those that suspend sensation in the whole body General anesthesia
2. Those that suspend sensation in certain parts of the body local,
regional, epidural or spinal anesthesia
General Anesthesia
This type of anesthesia promotes total loss of consciousness and sensation.
General anesthesia is commonly achieved when the anesthetic is inhaled or
administered intravenously. It affects the brain as well as the entire body.
Types of general anesthesia administration:
Volatile liquid anesthetics this type of anesthetic produces anesthesia when
their vapors are inhaled. Included in this group are the following:
1. Halothane (Fluothane)
2. Methoxyflurane (Penthrane)
3. Enflurane (Ethrane)
4. Isoflurane (Forane)
Gas Anesthetics anesthetics administered by inhalation and are ALWAYS
combined with oxygen. Included in this group are the following:

1. Nitrous Oxide
2. Cyclopropane
Stages
General anesthesia consists of four stages, each of which presents a definite
group of signs and symptoms.
Stage I: Onset or Induction or Beginning anesthesia.
This stage extends from the administration of anesthesia to the time of loss
of consciousness. The patient may have a ringing, roaring or buzzing in the
ears and though still conscious, is aware of being unable to move the
extremities easily. Low voices or minor sounds appear distressingly loud and
unreal during this stage.
Stage II: Excitement or Delirium.
Stage II extends from the time of loss of consciousness to the time of loss of
lid reflex. This stage is characterized by struggling, shouting, talking, singing,
laughing or even crying. However, these things may be avoided if the
anesthetic is administered smoothly and quickly. The pupils become dilated
but contract if exposed to light. Pulse rate is rapid and respirations are
irregular.
Stage III: Surgical Anesthesia.
This stage extends from the loss of lid reflex to the loss of most reflexes. It is
reached by continued administration of the vapor or gas. The patient now is
unconscious and is lying quietly on the table. Respirations are regular and
the pulse rate is normal.
Stage IV: Over dosage or Medullary or Stage of Danger.
This stage is reached when too much anesthesia has been administered. It is
characterized by respiratory or cardiac depression or arrest. Respirations
become shallow, the pulse is weak and thread and the pupils are widely
dilated and no longer contract when exposed to light. Cyanosis develops
afterwards and death follows rapidly unless prompt action is taken. To
prevent death, immediate discontinuation of anesthetic should be done and
respiratory and circulatory support is necessary.
Local Anesthesia

Local anesthetics can be topical, or isolated just to the surface. These are
usually in the form of gels, creams or sprays. They may be applied to the
skin before the injection of a local anesthetic that works to numb the area
more deeply, in order to avoid the pain of the needle or the drug itself
(penicillin, for example, causes pain upon injection).
Regional anesthesia
Regional anesthesia blocks pain to a larger part of the body. Anesthetic is
injected around major nerves or the spinal cord. Medications may be
administered to help the patient relax or sleep. Major types of regional
anesthesia include:
1. Peripheral nerve blocks. A nerve block is a shot of anesthetic near a
specific nerve or group of nerves. It blocks pain in the part of the body
supplied by the nerve. Nerve blocks are most often used for
procedures on the hands, arms, feet, legs, or face.
2. Epidural and spinal anesthesia. This is a shot of anesthetic near the
spinal cord and the nerves that connect to it. It blocks pain from an
entire region of the body, such as the belly, hips, or legs.
With regional anesthesia, an anesthetic agent is injected around the nerved
so that the area supplied by these nerves is anesthetized. The effect
depends on the type of nerve involved. The patient under a spinal or local
anesthesia is awake and aware of his or her surroundings.
Regional anesthesia carries more risks than local anesthesia, such as
seizures and heart attacks, because of the increased involvement of the
central nervous system. Sometimes regional anesthesia fails to provide
enough pain relief or paralysis, and switching to general anesthesia is
necessary.

Spinal Anesthesia
This is a type of conduction nerve block that occurs by introducing a local
anesthetic into the subarachnoid space at the lumbar level which is usually
between L4 and L5. Sterile technique is used as the spinal puncture is made
and medication is injected through the needle. The spread of the anesthetic
agent and the level of anesthesia depend on:
1. the amount of fluid injected
2. the speed with which it is injected

3. positioning of the patient after injection

4. specific gravity of the agent
Nursing Assessment
The following are nursing assessment after anesthesia:
1. Monitoring vital signs.
2. Observe patient and record the time when motion and sensation of the
legs and the toes return.
Side Effects
1. Some numbness or reduced feeling in part of your body (local
anesthesia)
2. Nausea and vomiting.
3. A mild drop in body temperature.
How do anesthesiologists determine the type of anesthesia to be
used?
The type of anesthesia the anesthesiologist chooses depends on many
factors. These include the procedure the client is having and his or her
current health.
Positioning
The nurse should have an idea which patient position is required for a certain
surgical procedure to be performed. There are lots of factors to consider in
positioning the patient which includes the following:
1. Patient should be in a comfortable position as possible whether he or
she is awake or asleep.
2. The operative area must be adequately exposed.
3. The vascular supply should not be obstructed by an awkward position
or undue pressure on a part.
4. There should be no interference with the patients respiration as a
result of pressure of the arms on the chest or constriction of the neck
or chest caused by a gown.

5. The nerves of the client must be protected from undue pressure.

Serious injury or paralysis may result from improper positioning of the
arms, hands, legs or feet.
6. Shoulder braces must be well padded to prevent irreparable nerve
injury.
7. Patient safety must be observed at all times.
8. In case of excitement, the patient needs gentle restraint before
induction.
Nursing Responsibilities
Here are the nursing responsibilities during intraoperative phase:
1. Safety is the highest priority.
2. Simultaneous placement of feet. This is to prevent dislocation of hip.
3. Always apply knee strap.
4. Arms should not be more than 90
5. Prepare and apply cautery pad. Cautery is used to stop bleeding.