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Chapter: Medical Surgical Nursing: Intraoperative Nursing Management

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The Surgical Team

The surgical team consists of the patient, the anesthesiologist or anesthetist, the surgeon, the intraoperative nurses, and the surgical technologists.

The Surgical Team

The surgical team consists of the patient, the anesthesiologist or anesthetist, the surgeon, the intraoperative nurses, and the surgical technologists. The anesthesiologist or nurse anesthetist administers the  anesthetic physical status throughout the surgery. The surgeon and assistants scrub and perform the surgery. The individual in the scrub role, either a nurse or surgical technologist, provides sterile instruments and supplies to the surgeon during the procedure. The circulating nurse coordinates the care of the patient in the operating room. Care provided by the circulating nurse includes assisting with patient positioning, preparing the patient’s skin for surgery, managing surgical specimens, and documenting intraoperative events.

THE PATIENT

As the patient enters the operating room, he or she may feel relaxed and prepared, or fearful and highly stressed. These feelings depend very much on the amount and timing of preoperative sedation and the patient’s level of fear and anxiety. Fears about loss of control, the unknown, pain, death, changes in body structure or function, and disruption of lifestyle all may contribute to a generalized anxiety. These fears can increase the amount of anesthetic needed, the level of postoperative pain, and overall recovery time.The patient is also subject to several risks. Infection, failure of the surgery to relieve symptoms, temporary or permanent complications related to the procedure or the anesthetic, and deathare uncommon but potential outcomes of the surgical experience (Chart 19-1). In addition to fears and risks, the patient undergoing sedation and anesthesia temporarily loses both cognitive func- tion and biologic self-protective mechanisms. Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury.


Gerontologic Considerations

Elderly patients face higher risks from anesthesia and surgery than younger adult patients (Polanczyk et al., 2001). Statistically,perioperative risk increases with each decade over 60 years, often because of the increased incidence of coexisting disease. Modifications tailored to the biologic changes of later life and the application of research findings for this population can reduce the risks.     

Biologic variations of particular importance include age-related cardiovascular and pulmonary changes (Townsend, 2002). The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. Excessive or rapid administration of intravenous solutions may cause pulmonary edema. A sudden or prolonged drop in blood pressure may lead to cerebral ischemia, thrombosis, embolism, infarction, and anoxia. Reduced gas ex-change can lead to cerebral hypoxia.

 

The elderly patient needs fewer anesthetics to produce anes-thesia and eliminates the anesthetic agent over a longer time than a younger patient. As people age, the percentage of lean body tis-sue decreases and fatty tissue steadily increases (from age 20 years to 90 years). Anesthetic agents that have an affinity for fatty tissue concentrate in body fat and the brain (Dudek, 2001). Lower doses of anesthetic are appropriate for another reason. The older patient, particularly when malnourished, may have low plasma protein lev-els. With decreased plasma proteins, more of the anesthetic agent remains free or unbound, and the result is more potent action.

 

Also in elderly adults, body tissues made up predominantly of water and those with a rich blood supply, such as skeletal muscle, liver, and kidneys, shrink. Reduced liver size decreases the rate at which the liver can inactivate many anesthetics, whereas de-creased kidney function slows elimination of waste products and anesthetics. Other factors affecting the elderly surgical patient in the intraoperative period include the following:

 

·        Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia.

 

·        Bone loss (25% in women, 12% in men) necessitates care-ful manipulation and positioning during surgery.

 

·        Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions.

 

As expected, mortality is higher with emergency surgery (com-monly required for traumatic injuries) than with elective surgery, making continuous and careful monitoring and prompt inter-vention especially important for older surgical patients (Phippen & Wells, 2000).

 

Nursing Care

 

Throughout surgery, nursing responsibilities include providing for the safety and well-being of the patient, coordinating the op-erating room personnel, and performing scrub and circulating activities. Because the patient’s emotional state remains a con-cern, the care begun by preoperative nurses is continued by the intraoperative nursing staff, who provide the patient with in-formation and realistic reassurance. The nurse supports coping strategies and reinforces the patient’s ability to influence out-comes by encouraging his or her active participation in the plan of care.

 

In the role of patient advocate, intraoperative nurses monitor factors that can cause injury, such as patient position, equipment malfunction, and environmental hazards, and they protect pa-tients’ dignity and interests while they are anesthetized. Addi-tional responsibilities include maintaining surgical standards of care, identifying existing patient risk factors, and assisting in modifying complicating factors to help reduce operative risk (Phippen & Wells, 2000).

 

THE CIRCULATING NURSE

 

The circulating nurse (also known as the circulator) must be a registered nurse. He or she manages the operating room and protects the patient’s safety and health by monitoring the ac-tivities of the surgical team, checking the operating room con-ditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. The main re-sponsibilities include verifying consent, coordinating the team, and ensuring cleanliness, proper temperature, humidity, and lighting; the safe functioning of equipment; and the availabil-ity of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinat-ing the movement of related personnel (medical, radiography, and laboratory) as well as implementing fire safety precautions (Phippen & Wells, 2000). The circulating nurse monitors the patient and documents specific activities throughout the oper-ation to ensure the patient’s safety and well-being. Nursing ac-tivities directly relate to preventing complications and achieving optimal patient outcomes.

 

THE SCRUB ROLE

 

Activities of the scrub role include performing a surgical hand scrub; setting up the sterile tables; preparing sutures, ligatures, and special equipment (such as a laparoscope); and assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments that will be required, such as sponges, drains, and other equipment (Phippen & Wells, 2000). As the surgical incision is closed, the scrub person and the cir-culator count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient. Tissue specimens obtained during surgery must also be labeled by the scrub person and sent to the laboratory by the circulator.

 

THE SURGEON

 

The surgeon performs the surgical procedure and heads the sur-gical team. He or she is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM) who is specially trained and qualified. Qualifications may include cer-tification by a specialty board, adherence to Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) standards, and adherence to hospital standards and admitting practices and procedures (Fortunato, 2000).

 

THE REGISTERED NURSE FIRST ASSISTANT

 

The registered nurse first assistant (RNFA) is another member of the operating room staff. Although the scope of practice of the RNFA depends on each state’s nurse practice act, the RNFA practices under the direct supervision of the surgeon. RNFA re-sponsibilities may include handling tissue, providing exposure at the operative field, suturing, and providing hemostasis. The en-tire process requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asep-sis. The competent RNFA needs to be aware of the objectives ofthe surgery, needs to have the knowledge and ability to anticipate needs and to work as a skilled member of a team, and needs to be able to handle any emergency situation in the operating room (Fortunato, 2000; Rothrock, 1999).

THE ANESTHESIOLOGIST AND 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. Most anesthetists are nurses who have graduated from an accredited nurse anesthesia program and have passed examinations sponsored by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). The anesthesiologist or anesthetist in-terviews and assesses the patient prior to surgery, selects the anes-thesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anes-thetic agent, and supervises the patient’s condition throughout the surgical procedure. Before the patient enters the operating room, often at preadmission testing, the anesthesiologist or anesthetist visits the patient to provide information and answer questions. The type of anesthetic to be administered, previous reactions to anes-thetics, and known anatomic abnormalities that would make air-way management difficult are discussed. The anesthesiologist or anesthetist uses the American Society of Anesthesiologists (ASA) Physical Status Classification System to determine the patient’s status (Chart 19-2).


 

When the patient arrives in the operating room, the anesthe-siologist or anesthetist reassesses the patient’s physical condition immediately prior to initiating anesthesia. The anesthetic is ad-ministered, and the patient’s airway is maintained either through a laryngeal mask airway (LMA) or an endotracheal tube. During surgery, the anesthesiologist or anesthetist monitors the patient’s blood pressure, pulse, and respirations as well as the electrocar-diogram (ECG), blood oxygen saturation level, tidal volume, blood gas levels, blood pH, alveolar gas concentrations, and body temperature. 

Monitoring by electroencephalography is some times required. Levels of anesthetics in the body can also be de-termined; a mass spectrometer can provide instant readouts of critical concentration levels on display terminals. The device also assesses the patient’s ability to breathe unassisted and indicates the need for mechanical assistance when ventilation is poor and the patient is not breathing well independently.

 

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