Intraoperative Care
Intraoperative care
Definition
The term "intraoperative" refers to the time during surgery. Intraoperative care is patient care during an operation and ancillary to that operation.
Activities such as monitoring the patient's vital signs , blood oxygenation levels, fluid therapy, medication transfusion, anesthesia, radiography, and retrieving samples for laboratory tests, are examples of intraoperative care. Intraoperative care is provided by nurses, anesthesiologists, nurse anesthetists, surgical technicians, surgeons, and residents, all working as a team.
Purpose
The purpose of intraoperative care is to maintain patient safety and comfort during surgical procedures. Some of the goals of intraoperative care include maintaining homeostasis during the procedure, maintaining strict sterile techniques to decrease the chance of cross-infection, ensuring that the patient is secure on the operating table, and taking measures to prevent hematomas from safety strips or from positioning.
Precautions
Patients undergoing surgery most often are given some type of anesthesia. The administration of general anesthesia has a relaxing effect on the patient's body, which can suppress cardiovascular function or heighten cardiovascular irritability. It may also result in respiratory depression, loss of consciousness, paralysis , and lack of sensation. These effects, some of which are intentional for the period of the surgery, mean the patient is in a very vulnerable position. It is the responsibility of the health care team in the operating room to maintain the patient's safety and yet facilitate surgery.
In 1992 the American Association of Nurse Anesthetists (AANA) established guidelines for monitoring patients undergoing general anesthesia. The guidelines call for continuous observation of the patient by the nurse assigned to the patient. Ventilation should be assessed by continuous auscultation of breath sounds, and oxygenation should be monitored by continuous pulse oximetry. Continuos electrocardiograph (ECG) showing the patient's cardiac function should be in place, and the patient's heart rate and blood pressure should be monitored at least every five minutes. A means to monitor the patient's temperature must be available immediately for use. In case of an emergency backup personnel who are experts in airway management , emergency intubation, and advanced cardiac life support (ACLS) must be available. An emergency cart containing the necessary supplies and equipment must be immediately accessible. The ACLS equipment should be checked daily to ensure proper function.
Total analgesia is a goal of general anesthesia in order to facilitate surgery. This means that the patient does not have the normal "pain" sensations that warn of potential injury. The health care team must keep this in mind when they are positioning the patient for a surgical procedure. Although it may be necessary for a patient to be positioned in an unusual way for access to a particular area during surgery, care must be taken to ensure that the patient's body is in proper alignment and that joints and muscles are not in such an unnatural position that they will be damaged if they remain in that position for a lengthy procedure. Areas of the operating table that come into contact with the patient's bony prominences must be padded to prevent skin trauma and hematomas.
During a surgical procedure many instruments, drapes, and sponges are used. Also, a multitude of care providers may be working in the operative field performing different tasks. These factors, combined with the complexity and length of some surgical procedures, may provide extensive opportunity for patient trauma from equipment malfunction or the failure of the surgical team to avoid using full weight on the sedated patient. Additionally, it is the responsibility of the nurses working in the operating room to maintain an accurate count of all sponges, instruments, and sharps that may become foreign bodies upon incision closure. Nurses who fail to make accurate counts can be held legally liable.
Most surgical procedures are invasive and compromise a patient's skin integrity. This increases the risk ofinfection . To decrease the risk, strict asepsis (sterile technique) must be followed at all times. It is recommended that the ventilation system in an operative area provide a minimum of fifteen exchanges of filtered air per hour. The temperature in the intraoperative area should be maintained at 68–73°F (20–23°C), and the relative humidity should be maintained at 30%–60%. Health care personnel who work in the operating room must not be permitted to work if they have open lesions on the hands or arms, eye infections, diarrhea , or respiratory infections. Scrub attire must be worn by all personnel entering the operating room. Fresh scrub attire must be donned daily and, if heavily soiled during one case, should be changed before the next case. Most facilities provide personnel with scrub attire that is professionally laundered. Shoe covers are required and should be changed often. Head and facial hair must be completely contained in a lint-free cap or hood. Properly fitting disposable surgical masks must be worn at all times and discarded immediately after use. Sterile gloves and sterile gowns must be worn by those working in, and in proximity to, the sterile field. Careful skin preparation with appropriate antiseptic solutions is preformed on the patient's arrival to the operating area.
Patients who have a known or suspected allergy to latex should be scheduled for surgery as the first case of the day whenever possible to avoid contact with airborne latex particles (often attached to powder granules from the gloves) that may be in the room from a previous surgery. These patients should also be identified (some facilities use special colored identification bands and colored tapes on the patient's medical record) so that all health care personnel can recognize them. Special care must be taken to limit the uses of equipment containing latex that will contact the patient's skin. This includes anesthesia masks, adhesive tape and dressings, injections drawn from multidose vials with rubber stoppers, adhesive ground plates for electrocautery or diathermy, and pad coverings on the operating table and arm extensions.
Description
Intraoperative care includes the activities performed by the health care team during surgery that ensure the patient's safety and comfort, implement the surgical procedure, monitor and maintain vital functions, and document care given. The intraoperative time period can vary greatly from less than one hour to 12 hours or more, depending on the complexity of the surgery being performed.
Preparation
Prior to surgery the patient or legal guardian must have the surgical procedure explained to them in great detail, including the expected outcomes and all possible complications, in order to give informed consent . The explanation should be given to the patient at a time when he or she is relaxed, but when judgment is not clouded by the use of any pain medication or anesthesia, which would invalidate the consent. A consent form must be signed by the patient or guardian and witnessed by a staff member as well as the surgeon performing the procedure. It is the duty of the RN admitting the patient to the surgical suite to check the patient's ID band and ensure that all records are intact and accounted for.
After consent is given the patient may be taken to a holding area where a large-bore intravenous catheter is inserted into the patient's arm for use in fluid replacement and to infuse medications during the procedure. The area of the body where the incision will be made is meticulously prepared using drapes, and a skin preparation that is antiseptic and may include the use of alcohol solutions and iodophor. Monitoring devices such as continuous ECG nodes, pulse oximetry probes, and a blood pressure cuff are usually applied prior to skin preparation. Anesthesia, also, is begun before skin prep. Surgery is then ready to begin.
Aftercare
The time after surgery is referred to as the postoperative period and includes the recovery and convalescence phases. The recovery phase is the time immediately after surgery when the effects of anesthesia are wearing off and the patient is waking up. The convalescence phase is spent either in the hospital, in an interim care facility, or at home—depending on the procedure and the preferences of the physician and patient.
Complications
Intraoperative complications are surgery related, anesthesia related, or position related. One complication occurring during the intraoperative period that is not common but can be life threatening is an anaphylactic (allergic) reaction to anesthesia. The intraoperative staff is trained extensively in the treatment of such a reaction, and emergency equipment should always be available in the event it is needed for this purpose. Another anesthesia-related complication is called "awareness under anesthesia." This occurs when the patient receives sufficient muscle relaxant (paralytic agent) to prohibit voluntary motor function but insufficient sedation and analgesia to block pain and the sense of hearing . Patients are aware
KEY TERMS
Anaphylactic reaction (anaphylaxis) —A hyper-sensitive reaction to an antigen resulting in life-threatening, progressive symptoms.
Anesthesia —A classification of medications that are intended to cause the loss of normal sensation.
Aseptic technique —Strict sterile procedures instilled to decrease the risk of contamination of a surgical site or open wound.
ECG —Abbreviation for electrocardiograph. Electro-cardiograph is a tracing of the electrical activity of the heart obtained through electrodes placed on a person's skin in certain areas where electrical activity can be easily be detected.
Hypovolemic shock —A state of shock caused by the sudden loss of large amounts of blood.
Informed consent —Written or oral permission given by a patient or guardian for medical or surgical treatment after a complete explanation is given and any questions the patient has are answered. If consent is given orally, documentation must have two witnesses.
Intraoperative care —Care provided to a patient during surgery that is ancillary to the surgery.
Malignant hyperthermia —A chain reaction triggered in susceptible people by commonly used general anesthetics. Signs include greatly increased body metabolism, muscle rigidity, and eventual hyperthermia which may exceed 110°F(43.3°C). Death may be caused by cardiac arrest, brain damage, internal hemorrhage, or failure of other body systems.
Pulmonary function tests —Tests used to determine ventilation and perfusion capabilities of the lungs.
Pulse oximetry —A method of measuring a patient's blood oxygenation status. A measure of 100% is optimal.
of being "awake" because they hear the sounds and conversation in the room and, in some cases, can feel the pain associated with the skin incision and surgery. However, they cannot respond to these sensations in a way—not even with so small a motion as blinking the eyelid—that will tell someone what they are sensing. This condition creates an exaggerated fear response that can affect hemodynamics and vital signs. Another complicating reaction may be that of malignant hyperthermia. This is a chain reaction triggered in susceptible people by commonly used general anesthetics. Signs include greatly increased body metabolism , muscle rigidity, and eventual hyperthermia which may exceed 110°F(43.3°C). Death may be caused by cardiac arrest, brain damage, internal hemorrhage, or failure of other body systems.
Complications of surgery include, but are not limited to, hypovolemic shock (due to blood loss during surgery), injuries from poor positioning during surgery, infection of the surgical wound, fluid and electrolyte imbalances, aspiration pneumonia , blood clots, and paralytic ileus (paralysis of the intestines, causing distention).
Results
The results of a surgical procedure depend greatly on the procedure preformed, the skill of the surgeon, the general health of the patient preoperatively, and the ability of the patient's body to recover from the procedure. Some surgeries cure a condition (e.g., an appendectomy for an inflamed appendix). Others are only one step in a long process to cure a disease or repair an injury (e.g., discectomy for a patient suffering from back pain). Still others are performed as palliative measures rather than as a cure. An example of palliative surgery would be the removal of a metastatic abdominal tumor to relieve abdominal pressure. In this example removing the abdominal tumor is not going to cure the cancer that exists in other parts of the patient's body; it is simply going to relieve the discomfort caused by the abdominal mass.
Health care team roles
Nurses may fill two different roles in the operating room. The scrub nurse is responsible for providing the surgeon with instruments and supplies and maintaining the sterile field. This role also may be assumed by a scrub or surgical technician. The second role nurses have in the operating room is that of circulating nurse. The circulating nurse is first the patient's advocate, with primary concern and responsibility for the patient's safety and welfare. In addition, the circulating nurse is responsible for anything related to the patient that is not directly contingent to the sterile field. That means all activities necessary to prepare the patient and the operative site for surgery, and assistance required by anesthesia personnel. Of crucial import is that the circulating nurse must be certified to give intravenous medication to the patient in case of an emergency. Finally, nurses must document and process tissue specimens for pathology.
Resources
BOOKS
Potter, Patricia A., and Anne G. Perry. Fundamentals ofNursing Concepts, Process, and Practice. 4th ed. St. Louis, Missouri: Mosby-Year Book, Inc., 1997.
PERIODICALS
Armstrong, D, and P. Bortz. "An Integrative Review of Pressure Relief in Surgical Patients." AORN Journal 73, no. 3 (March 2001): 645-8, 650-3, 656-7.
Byers, P.H., S.G. Carta, and H.N. Mayrovitz. "Pressure Ulcer Research Issues in Surgical Patients." Advances in Skin Wound Care 13, no. 3 (May-June 2000): 115-21.
Kleinveck, S.V., and M. McKennett. "Challenges of Measuring Intraoperative Patient Outcomes." AORN Journal 72, no. 5 (November 2000): 845-50, 853.
Truell, K.D., P.R. Bakerman, M.F. Teodori, and A. Maze. "Third-Degree Burns Due to Intraoperative Use of a Bair Hugger Warming Device." Annals of Thoracic Surgery 69, no. 6 (June 2000): 1933-4.
Wolfson, K.A., L. L. Seeger, B.M. Kadell, and J.J. Eckardt. "Imaging of Surgical Paraphernalia: What Belongs in the Patient and What Does Not." Radiographics 20, no. 6 (November-December 2000): 1665-73.
OTHER
Intraoperative Care Website. Jack Stem's Midwest Anesthesia Consultants, 2001. <http://www.jackstem.com/intraoperative_care.htm>.
Perioperative, Intraoperative, Postoperative Care InfectionControl Policy Manual Henry Ford Health System, 1998. <http://www.hfhsmanuals.com/ICM/Invasive%20Procs/ peroperative.htm>.
Jennifer Lee Losey, R.N.