19
Intraoperative Care
Kimberly Day and Debra Hagler
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Safety
Pain Tissue Integrity
Perfusion
LEARNING OUTCOMES
1. Describe appropriate attire for various areas of the 5. Apply basic principles of infection prevention and aseptic
perioperative department. technique in the operating room.
2. Outline the roles and responsibilities of surgical team 6. Recognize operating room safety measures related to
members. patients, equipment, and anesthesia.
3. Prioritize needs of patients undergoing surgery. 7. Describe various anesthesia techniques and common
4. Analyze role of a perioperative nurse in managing patients anesthesia drugs.
undergoing surgery.
KEY TERMS
anesthesia care provider (ACP) malignant hyperthermia (MH)
anesthesiology nurse anesthetist
epidural block regional anesthesia
general anesthesia spinal anesthesia
local anesthesia
Historically, surgery took place in the hospital operating room those in scrub attire. These areas typically include the points of
(OR). Now, many patients have surgery in outpatient settings. entry for patients (e.g., preoperative holding area), staff (e.g.,
More surgeons are using minimally invasive surgery (MIS) locker rooms), and information (e.g., nursing station or control
techniques and advanced technologies such as endoscopes and desk). The semirestricted zone includes the surrounding support
robotics that decrease blood loss, incision size, pain, recovery areas and corridors. Only authorized staff are allowed access to
time, and hospital length of stay. Hybrid ORs, which allow for semirestricted areas. All staff in the semirestricted area should
MIS and traditional open incision approaches within the same wear clean surgical attire. This includes scrub attire that was
room, are becoming more common. This chapter describes the laundered in an accredited laundry facility, long-sleeved jacket,
basics of intraoperative care that apply to all surgical patients, shoes dedicated for surgery use or shoe covers, surgical head
regardless of where or how the surgery is done. cover that covers all head and facial hair, and any appropriate
personal protective equipment (e.g., face shield). The restricted
PHYSICAL ENVIRONMENT OF THE zone is found within the semirestricted area. It includes the OR
OPERATING ROOM or surgical suite where the procedure takes place and the sterile
core (Fig. 19.2). Masks should be worn and traffic minimized
Department Layout when sterile supplies are open in the restricted area.1–3
The surgery department is a controlled environment designed The physical layout is designed to reduce cross-contamination.
to minimize the spread of pathogens and allow a smooth flow The flow of clean and sterile supplies and equipment is separate
of patients, staff, and equipment for safe surgical patient care. from contaminated supplies, equipment, and waste. Staff move
The department is divided into 3 distinct zones: (1) unre- supplies from clean areas, such as the sterile core, through the OR
stricted, (2) semirestricted, and (3) restricted (Fig. 19.1). The for surgery, and on to the instrument decontamination and steril-
unrestricted zone is where people in street clothes interact with ization area (e.g., central processing department [CPD]).
350
, CHAPTER 19 Intraoperative Care 351
TO LOCKER
ROOMS HOLDING TO FAMILY WAITING AREA POST-ANESTHESIA TO INTENSIVE
NURSES
STATION AREA RECOVERY UNIT CARE UNIT
TO CENTRAL
PROCESSING UNRESTRICTED ZONE
SEMI-RESTRICTED ZONE
OR #1 OR #2
SCRUB SINK SCRUB SINK
SEMI-RESTRICTED SEMI-RESTRICTED
RESTRICTED AREA
AREA AREA
SCRUB SINK SCRUB SINK
STERILE
CORE
OR #4 OR #3
Fig. 19.1 Perioperative department layout.
care unit allows for quick transport of the patient after surgery
and close proximity to anesthesia staff if complications occur.
We use several methods to prevent the transmission of infec-
tion in the OR. Filters and controlled airflow in the ventilating
systems provide dust control. Positive air pressure in the rooms
prevent air from entering the OR from the halls and corridors.
Temperature and humidity are controlled to prevent bacterial
growth. Ultraviolet lighting reduces the number of microorgan-
isms in the air. ORs have strict protocols for cleaning between
cases and terminal cleaning at the end of the day.1–3
Furniture that is adjustable, easy to clean, and easy to move
promotes safety and comfort. We check equipment frequently to
ensure proper functioning and electrical safety. The lighting is
designed for a precise view of the surgical site. A communication
Fig. 19.2 Typical OR. (© iStock.com/windslegend.) system offers a way to deliver routine and emergency messages.
Preoperative Holding Area SURGICAL TEAM
The preoperative holding area is an unrestricted zone where
patient identification and assessment take place. In some set- Registered Nurse
tings, the holding area is called the admission, observation, The perioperative nurse is a registered nurse (RN) who works
and discharge (AOD) unit. An AOD unit is designed to allow with the rest of the surgical team and implements the patient’s
early morning admission for outpatient surgery, same-day plan of care during the perioperative period. Depending on
admission, and inpatient holding before surgery. The patient is the size of the OR department, this role may include 3 domains:
identified and assessed before and after surgery, before being (1) preoperative RN, (2) OR RN, and (3) PACU RN. As an OR
discharged home or transferred to an inpatient room. The AOD RN, you are the patient’s advocate during surgery. This includes
unit is important in outpatient surgery and prevents unneces- (1) maintaining the patient’s safety, dignity, and confidential-
sary overnight stays in the inpatient setting. ity; (2) communicating with the patient, the surgical team, and
other departments (e.g., CPD, PACU, laboratory); and (3) pro-
Operating Room viding nursing care as described in this chapter.
The traditional OR is a unique setting separate from other clini- During surgery, the OR RN assumes functions that involve
cal units. This restricted zone is controlled geographically, envi- either sterile or unsterile activities (Table 19.1). The scrub nurse
ronmentally, and aseptically (Fig. 19.1). Having the OR next to (sterile) follows the designated surgical hand antisepsis with
the postanesthesia care unit (PACU) and the surgical intensive sterile glove and gown attire. They prepare and manage the
Intraoperative Care
Kimberly Day and Debra Hagler
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Safety
Pain Tissue Integrity
Perfusion
LEARNING OUTCOMES
1. Describe appropriate attire for various areas of the 5. Apply basic principles of infection prevention and aseptic
perioperative department. technique in the operating room.
2. Outline the roles and responsibilities of surgical team 6. Recognize operating room safety measures related to
members. patients, equipment, and anesthesia.
3. Prioritize needs of patients undergoing surgery. 7. Describe various anesthesia techniques and common
4. Analyze role of a perioperative nurse in managing patients anesthesia drugs.
undergoing surgery.
KEY TERMS
anesthesia care provider (ACP) malignant hyperthermia (MH)
anesthesiology nurse anesthetist
epidural block regional anesthesia
general anesthesia spinal anesthesia
local anesthesia
Historically, surgery took place in the hospital operating room those in scrub attire. These areas typically include the points of
(OR). Now, many patients have surgery in outpatient settings. entry for patients (e.g., preoperative holding area), staff (e.g.,
More surgeons are using minimally invasive surgery (MIS) locker rooms), and information (e.g., nursing station or control
techniques and advanced technologies such as endoscopes and desk). The semirestricted zone includes the surrounding support
robotics that decrease blood loss, incision size, pain, recovery areas and corridors. Only authorized staff are allowed access to
time, and hospital length of stay. Hybrid ORs, which allow for semirestricted areas. All staff in the semirestricted area should
MIS and traditional open incision approaches within the same wear clean surgical attire. This includes scrub attire that was
room, are becoming more common. This chapter describes the laundered in an accredited laundry facility, long-sleeved jacket,
basics of intraoperative care that apply to all surgical patients, shoes dedicated for surgery use or shoe covers, surgical head
regardless of where or how the surgery is done. cover that covers all head and facial hair, and any appropriate
personal protective equipment (e.g., face shield). The restricted
PHYSICAL ENVIRONMENT OF THE zone is found within the semirestricted area. It includes the OR
OPERATING ROOM or surgical suite where the procedure takes place and the sterile
core (Fig. 19.2). Masks should be worn and traffic minimized
Department Layout when sterile supplies are open in the restricted area.1–3
The surgery department is a controlled environment designed The physical layout is designed to reduce cross-contamination.
to minimize the spread of pathogens and allow a smooth flow The flow of clean and sterile supplies and equipment is separate
of patients, staff, and equipment for safe surgical patient care. from contaminated supplies, equipment, and waste. Staff move
The department is divided into 3 distinct zones: (1) unre- supplies from clean areas, such as the sterile core, through the OR
stricted, (2) semirestricted, and (3) restricted (Fig. 19.1). The for surgery, and on to the instrument decontamination and steril-
unrestricted zone is where people in street clothes interact with ization area (e.g., central processing department [CPD]).
350
, CHAPTER 19 Intraoperative Care 351
TO LOCKER
ROOMS HOLDING TO FAMILY WAITING AREA POST-ANESTHESIA TO INTENSIVE
NURSES
STATION AREA RECOVERY UNIT CARE UNIT
TO CENTRAL
PROCESSING UNRESTRICTED ZONE
SEMI-RESTRICTED ZONE
OR #1 OR #2
SCRUB SINK SCRUB SINK
SEMI-RESTRICTED SEMI-RESTRICTED
RESTRICTED AREA
AREA AREA
SCRUB SINK SCRUB SINK
STERILE
CORE
OR #4 OR #3
Fig. 19.1 Perioperative department layout.
care unit allows for quick transport of the patient after surgery
and close proximity to anesthesia staff if complications occur.
We use several methods to prevent the transmission of infec-
tion in the OR. Filters and controlled airflow in the ventilating
systems provide dust control. Positive air pressure in the rooms
prevent air from entering the OR from the halls and corridors.
Temperature and humidity are controlled to prevent bacterial
growth. Ultraviolet lighting reduces the number of microorgan-
isms in the air. ORs have strict protocols for cleaning between
cases and terminal cleaning at the end of the day.1–3
Furniture that is adjustable, easy to clean, and easy to move
promotes safety and comfort. We check equipment frequently to
ensure proper functioning and electrical safety. The lighting is
designed for a precise view of the surgical site. A communication
Fig. 19.2 Typical OR. (© iStock.com/windslegend.) system offers a way to deliver routine and emergency messages.
Preoperative Holding Area SURGICAL TEAM
The preoperative holding area is an unrestricted zone where
patient identification and assessment take place. In some set- Registered Nurse
tings, the holding area is called the admission, observation, The perioperative nurse is a registered nurse (RN) who works
and discharge (AOD) unit. An AOD unit is designed to allow with the rest of the surgical team and implements the patient’s
early morning admission for outpatient surgery, same-day plan of care during the perioperative period. Depending on
admission, and inpatient holding before surgery. The patient is the size of the OR department, this role may include 3 domains:
identified and assessed before and after surgery, before being (1) preoperative RN, (2) OR RN, and (3) PACU RN. As an OR
discharged home or transferred to an inpatient room. The AOD RN, you are the patient’s advocate during surgery. This includes
unit is important in outpatient surgery and prevents unneces- (1) maintaining the patient’s safety, dignity, and confidential-
sary overnight stays in the inpatient setting. ity; (2) communicating with the patient, the surgical team, and
other departments (e.g., CPD, PACU, laboratory); and (3) pro-
Operating Room viding nursing care as described in this chapter.
The traditional OR is a unique setting separate from other clini- During surgery, the OR RN assumes functions that involve
cal units. This restricted zone is controlled geographically, envi- either sterile or unsterile activities (Table 19.1). The scrub nurse
ronmentally, and aseptically (Fig. 19.1). Having the OR next to (sterile) follows the designated surgical hand antisepsis with
the postanesthesia care unit (PACU) and the surgical intensive sterile glove and gown attire. They prepare and manage the
