Perioperative

IntraOp Care – p169

NURS 3512
Barb Goodwin RN MN
 Guided Study Questions: Intra-Op Care
• Physical Environment in the OR
• the Surgical Team: Surgeon, Anesthesiologist, Scrub Nurse, Circulating
Nurse
• Types/Classifications of Anesthesia
• Malignant Hyperthermia (p155)

The OR operating room is also called the… “surgical suite, OR theater,

OR, theater…”
 Physical Environment of the OR
• OR rooms/theatres and the OR “area/wing” of the hospital
• traffic flow - personnel & supplies (clean/dirty)

• Controlled environment design/physical space – minimize infection &

have equipment easy to “clean”
• *think of what you see and what you cant see
• air
• temperature
• furniture
• lighting
https://www.hunterdonhealthcare.org/service/surgery/operating-room/operating-room-web-copy/
https://www.smgh.ca/wp-content/uploads/2018/11/Cardiac-operating-room-wide-shot.jpg
 Areas of the OR: Controlled Access
• maximum infection control in an environment that makes sense for the work that
needs to happen.
• Access - who can go where & what do they wear

• 3 main areas
Unrestricted Area
• Can be in street clothes

Semi-restricted area
• Must wear surgical attire & cover all hair

Restricted area
• Surgical attire, cover all hair & surgical mask

• Ana
 CODE BLUE CART

SCRUBS MH CART

FEMALE MALE ELEVATOR LOUNGE

SECURITY
LOCKERS LOCKERS ACCESS PANEL

MASKS
&
HATS
STERILE PROCESSING DECONTAM
MASKS
&
HATS
CORRIDOR

5 4 3 2 1 MAIN DESK
ENT GENERAL GYNE UROLOGY
SIGN IN
ACCESS KEY

CORRIDOR
WEST SUPPLY AREA

L2016
10 9 8 7 6 SM
CONF
ENT ECT,C/S PLASTICS GENERAL DAY SURG RM
H/N ACSS L2014
LG
CORRIDOR CONF
PREOP RM

15 14 12 11 HOLDING
CARDIAC CARDIAC CARDIAC VASCULAR (POH)
MEET PATIENT,
CONSENT PRN DOUBLE DOORS
2ND FLOOR
EAST SUPPLY AREA L BLOCK
 Surgeon, Anesthesiologist, RNs (scrub, circulating)
- all follow principles of aseptic technique

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/operating-room-team/#google_vignette
 Who’s Who? Surgical Team Members
Surgeon
• Determines the need for & type
of surgery
• Does surgery, got consent
• Care (orders) on unit

Anesthesiologist
• Keeps pt alive & ensures the
anesthesia is maintained
• Care in RR/PACU
• Gives the meds, VS, airway, i&o

Circulating and Scrub Nurses

• See next slide
http://nursingcrib.com/tag/operating-room
Nursing Roles in the OR:
Circulating Nurse(s)
• unsterile field
• deals with pt
• “runs the ship”
• contact with outside world!

file:///C:/Users/townsend/Downloads/RN-Circulator-Flyer.pdf

Scrub Nurse
• sterile field
• “in there”

Both do the “count”

http://msuprospectivenurses.blogspot.com/2015/10/perioperative-nursing.html
 Patient Positioning A. Supine position B.Trendelenburg position: C. Lithotomy
position D. Lateral decubitus position E.Prone position with a
Wilson frame
Goals
• do the surgery
• monitor – safety
• can give meds
• don’t injure the pt
• alignment
• secure extremities
• padding, support

https://pageburstls.elsevier.com/books/978-1-926648-70-5/
id/B9781926648705000217_f0035
 Anesthesia or “Anesthetic given”
• An artificially induced state of partial/total loss of sensation with/without
consciousness
• Type of anesthetic to be given is determined by:
• procedure
• past health hx
• preference
• Classifications of anesthetics:
• general (GA)
• regional/local
• procedural sedation (conscious sedation) – Fentanyl & Versed (Midazolam)

What is the difference – what is the expected way & time the pt would
recover from the anesthetic they received? How/what do we monitor? What
could go wrong?
General Anesthesia (GA)

http://intranet.tdmu.edu.ua/data/kafedra/internal/anest_critical/classes_stud/en/med/lik/ptn/Anesthesiology/5/Topic%2003.%20Clinical
%20anaesthesiology.htm
 General Anesthesia (GA): How is it Given?
Anesthesiologist
• IV Induction
• IV induction med (propofol)

• Inhalation Agents – “foundation to anesthesia”

• “gas” to breath in
• given face mask then likely endotracheal tube
(placed once IV induction agent given)

• Adjuncts to General Anesthesia

• IV drugs given to achieve
• unconsciousness
• amnesia
• muscle relaxation
• ANS control

http://airway.jems.com/wp-content/
uploads/2011/04/Jan_08_JEMS_intubation101.jpg
 Local Anesthesia
• Block electrical impulses along nerve fibers to specific part of body
• Awake
• Recover fast
• No NPO preop

Topical
• Apply to skin, mucous membranes

Regional
• Injection of local anesthetic
• in or around nerve group
• into CSF in subarachnoid space (Spinal Anesthetic) or
• nerve roots around spine (Epidural Anesthetic) to achieve anesthesia for surgery of
lower extremities.
 Spinal/Epidural Anesthesia
Spinal –one time injection of • spinal vs epidural
anesthetic & analgesia to
subarachnoid space (usually below
L2)
• Mixes with CSF
• Autonomic, sensory and motor blockade

Epidural – injection of
anesthetic/analgesia in epidural
space (lumbar or thoracic)
• Drug binds to nerve roots entering/exiting
spinal cord
• Sensory fibers blocked, motor fibers intact
• Can be a one-time dose for surgery or left in to
continue as analgesia for post-op use (pump) http://www.buzzle.com/articles/difference-between-spinal-and-
epidural-block.html
 Spinal/Epidural Anesthesia
Post-Op Monitoring for potential complications of:

• Hypotension
• Pruritis
• Urinary retention
• N&V
• Infection / Septicemia
• Epidural hematoma
• Spinal headache (with spinal)

http://www.centurionmp.com/products/sorbaview-shield/
 Procedural “Conscious” Sedation
Mild or heavy deep IV sedation for minor surgical procedures or diagnostic
procedures (tooth extraction, endoscopy, wound debridement)
- pediatrics
• Fentanyl & Versed (Midazolam)
• ABCs
• Frequent VS
• Nurse – critical care or specialty training in conscious sedation
SurgicalTime Out/Surgical Safety Checklist p151

https://www.youtube.com/watch?v=UoYOdmDX4rA
 Malignant Hyperthermia p155
• *awareness, planning, early recognition & intervention
• genetic

• triggered by certain drugs used for anaesthetic (certain inhalation gases &
Succinylcholine)!
• what happens?
• increased Ca+ levels in muscle cells
• increased muscle metabolism
• myoglobinuria bc of rhabdomyolysis

• treatment
• medication - Dantrolene sodium (skeletal muscle relaxant)
• cool the patient
 Recovery Room/PostAnaesthesia Care Unit
• Postanesthesia care unit (PACU)
• No visitors
• Very close proximity to the OR
• Pt on stretcher
• Anesthesiologist brings pt & gives report to RN
• Surgeon updates family in waiting room
• “open area”
• “golden time”
• Discharge Criteria – “ready for the ward”
https://nurseslabs.com/postoperative-phase/
PACU RN “gives report” to unit nurse p171
• What surgery was performed, pt age & name, time frame
• Anesthetic given
• Allergies (latex, drugs)
• Past medical hx
• Any intraop or RR problems – & what was the treatment
• Fluids given in the OR (including blood pdcts), i&o balance, iv fluid now
• Lines, incision, dressings, drainage, O2 if on
• Last dose of analgesia, when next med is due (likely antibiotic)
• Current VS, temp, O2 sat%
• Family, surgeon communication