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 anethesia 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 during the Intraoperative Phase 1. Promote the principle of asepsis. 2. Homeostasis 3. Safe administration of anesthesia 4. y Hemostasis To help decrease microbes, the surgical area is divided into three zones: the unrestricted zone, where street clothes are allowed; the semirestricted zone, where

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. As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the 4. patient. 5. Circulating Nurse (also known as the circulator) respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan. 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. 2. 3. 4. 5. 6. Assures cleanliness in the OR. Guarantees the proper room temperature, humidity and lighting in OR. Make certain that equipments are safely functioning. Ensure that supplies and materials are available for use during surgical procedures. Monitors aseptic technique while coordinating the movement of related personnel.

attire consists of scrub clothes and caps; and the restricted zone, where scrub clothes, shoe covers, caps,and masks are worn. y The Association of PeriOperative Registered Nurses, formerly known as the Association of Operating Room Nurses (and still abbreviated as AORN), recommends specific practices for those wearing surgical attire to promote a high level of cleanliness in a particular practice setting 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 An anesthesiologist is a physician specifically trained in the art and science of anesthesiology.An anesthetist is a qualified health care professional who administers anesthetics. 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

Monitors the patient throughout the operative procedure to ensure the persons safety and well being. Scrub Nurse 1. Scrubbing for surgery. 2. 3. 4. Setting up sterile tables. Preparing sutures and special equipments. Assists the surgeon and assistant during the surgical procedure by anticipating the required instruments, sponges, drains and other equipment. Keeps track of the time the patient is under anesthesia and the time the wound is open. Checks equipments and materials such as needles,

5. 6.

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 Good Description No organic disease; no systemic disturbance Mild to moderate systemic disturbance Severe systemic disturbance Systemic disease threatening life Little chance of survival but submitting to operation in desperation Any of the abive when surgery is performed in an emergency situation Example Uncomplicated hernias, fracture

3deep sedation Deep sedation is a drug-induced state during which a patient cannot be easily aroused but can respond purposefully after repeated stimulation 4Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. 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 2. General anesthesia 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. 1. 2. 3. 4. Included in this group are the following: Halothane (Fluothane) Methoxyflurane (Penthrane) Enflurane (Ethrane) Isoflurane (Forane) Gas Anesthetics anesthetics administered by inhalation and are ALWAYS combined with oxygen. Included in this group are the following:

Fair

Mild cardiac (I and II) disease, mild diabetes

Poor

Poorly controlled diabetes, pulmonary complications, moderate cardiac (III) disease Severe renal disease, severe cardiac disease (IV), decompensation Massive pulmonary embolus, ruptured abdominal aneurysm with profound shock An uncomplicated hernia that is now strangulated and associated with nausea and vomiting.

Serious

Moribund

Emergency

1. Nitrous Oxide 2. Cyclopropane Stages of General Administration 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

Sedation and anesthesia have four levels: 1minimal sedation is a drug-induced state during which the patient can respond normally to verbal commands. Cognitive function and coordination may be impaired 2moderate sedation Its goal is a calm, tranquil, amnesic patient who, when sedation is combined with analgesic agents, is relatively pain-free during the procedure but able to maintain protective reflexes,

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: Overdosage 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. Epidural and spinal anesthesia. This is a shot of

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. 2. 3. 4. the amount of fluid injected the speed with which it is injected positioning of the patient after injection specific gravity of the agent

Nursing Assessment after Spinal Anesthesia 1. Monitoring vital signs. 2. Observe patient and record the time when motion and sensation of the legs and the toes return. 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. Epidural and spinal anesthesia. This is a shot of anesthetic near the spinal cord and the nerves that

2.

2.

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

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 after Spinal Anesthesia 1. Monitoring vital signs. Observe patient and record the time when motion and sensation of the legs and the toes return. Anesthetists and anesthesiologists use the American Society of Anesthesiologists Physical (P) Status Classification System to describe the patients general status and identify potential risks during surgery. There are five classes of physical status. P 1. A normally healthy patient Example: No systemic abnormality, localized infection without fever, benign tumor, hernia P 2. A patient with mild systemic disease Example: Well-controlled hypertension, well-controlled diabetes mellitus, chronic bronchitis, obesity, age over 80 P 3. A patient with severe systemic disease that is not incapacitating Example: Severe disease, compensated heart failure, myocardial infarction more than 6 mo ago, angina pectoris, severe dysrhythmia, cirrhosis, poorly controlled diabetes or hypertension, ileus P 4. A patient with an incapacitating systemic disease that is a constant threat to life Example: Severe heart failure, myocardial infarction less than 6 mo ago, severe respiratory failure, advanced liver or renal failure P 5. A moribund patient who is not expected to survive for 24 hours with or without operation Example: Unconscious patient with traumatic head injury and agonal cardiac rhythm Basic Guidelines for Maintaining Surgical Asepsis All practitioners involved in the intraoperative phase have a responsibility to provide and maintain a safe environment. Adherence to aseptic practice is part of this responsibility. The eight basic principles of aseptic technique follow: All materials in contact with the surgical wound and used within the sterile field must be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and 2.

remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 inches above the elbow to the stockinette cuff. Sterile drapes are used to create a sterile field. Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back. Items should be dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. After a sterile package is opened, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact. The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Scrubbed persons and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. Movement around a sterile field must not cause contamination of the field. Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination. Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced. Every sterile field should be constantly monitored and maintained. Items of doubtful sterility are considered unsterile. Sterile fields should be prepared as close as possible to the time of use.