Intraoperative Phase, Surgical Team, Positions during Surgery

INTRAOPERATIVE PHASE Size of the Procedure Room

extends from the time the client is admitted to the OR, ➢ Usually rectangular or square in shape
to the time of administration of anesthesia, surgical ➢ 20x 20 x 10 with a minimum floor space of 360
procedure is done, until he/she is transported to the square feet
RR/PACU.
➢ Each procedure room must have the following
equipment:
INTRAOPERATIVE PHASE GOALS
✓ Communication System, Cardiac defibrillator
✓ Asepsis ✓ Oxygen and vacuum outlets
✓ Homeostasis ✓ Mechanical ventilation assistance equipment
✓ Safe Administration of Anesthesia ✓ Respiratory and Cardiac monitoring equipment
✓ Hemostasis ✓ X ray film illumination boxes
✓ High-efficiency particulate air filters
✓ Adequate room lighting
Surgical Setting ✓ Emergency lighting system
Unrestricted provides an entrance and exit from
Area the surgical suite for personnel,
equipment and patient. GUIDE FOR OPERATING ROOM
Environmental ▪ The size of the procedure room
Yellow uniform street clothes are permitted in this ▪ Temperature and humidity
Safety
area, and the area provides access to control
with apron (Prevents
communication with personnel within ▪ Ventilation and air exchange
the suite and with personnel and airborne
system (15x)
patient’s families outside the suite. infection) ▪ Electrical Safety
▪ Communication System (phone)
Semi-restricted provides access to the procedure
Area rooms and peripheral support areas Temperature ✓ The temperature in the
within the surgical suite. and Humidity procedure room should
Control maintained between 68 F - 75 F
personnel entering this area must be in (20 - 24 degrees C)
Green scrubs,
proper operating room attire and traffic ✓ Humidity level between 50 - 55
shoe covers, % at all times
control must be designed to prevent
cap, mask violation of this area by unauthorized Ventilation and Air exchange in each procedure room
persons. Air Exchange should be at least 25 air exchanges
System every hour, and five of that should be
peripheral support areas consists of: fresh air.
storage areas for clean and sterile
supplies, sterilization equipment and A high filtration particulate filter,
corridors leading to procedure room working at 95% efficiency is
recommended.
Restricted Area includes the procedure room where
surgery is performed and adjacent Each procedure room should
Green scrubs, sub sterile areas where the scrub sinks maintained with positive pressure,
shoe cover, and autoclaves are located which forces the old air out of the room
cap, mask, OR and prevents the air from surrounding
gown and personnel working in this area must be areas from entering into the procedure
gloves, eye in proper operating room attire room.
protector. Electrical Faulty wiring, excessive use of
Safety extension cords, poorly maintained
equipment and lack of current safety
RMC & QMMC Operating Room Set Up
measures are just some of the
hazardous factors that must be
constantly checked.

All electrical equipment new or used,

should be routinely checked by
qualified personnel.

Equipment that fails to function at

100% efficiency should be taken out of
service immediately.
Intraoperative Phase, Surgical Team, Positions during Surgery
The Surgical Team
▪ The Patient – receiving care or procedure to be
done to return to optimal status.
▪ The Anesthesiologist – license physician or may
specialization sa pagsaksak ng anesthesia.
▪ Anesthetist or CRNA
▪ The Surgeon – captain of the ship
▪ Scrub Nurse – handles equipments, count
instruments, helper surgeon if walang 1 st assistant
▪ Circulating Nurse – need na RN, holds the chart
▪ RNFA (Reg.Nurse First Assistant)
▪ Surgical Technologists – technician, machine
PRIMARY RESPONSIBILITIES
Surgeon ✓ Primary responsible for the
preoperative medical history
and physical assessment.
✓ Performance of the operative
procedure according to the
needs of the patients.
✓ The primary decision maker
regarding surgical technique to
use during the procedure.
✓ May assist with positioning
and prepping the patient or
may delegate this task to other
members of the team
First Assistant ✓ May be a resident, intern,
to the Surgeon physician’s assistant or a
perioperative nurse.
✓ Assists with retracting (opens
the incision site), hemostasis
(maintains no bleeding),
suturing (close suturing w/
supervision) and any other
tasks requested by the surgeon
to facilitate speed while
maintaining quality during the
procedure.
*Intern – graduate ng MD (no BE)
*Resident – may license na
*Clerk – student doctor
Anesthesiologist ✓ Selects the anesthesia,
administers it, intubates the
client if necessary, manages
technical problems related to
the administration of anesthetic
agents, and supervises the
client’s condition throughout
the Surgical procedure.
✓ A physician who specializes in
the administration and
monitoring of anesthesia
while maintaining the overall
well-being of the patient.
Scrub Nurse ✓ May be either a nurse or a
Surgical technician.
✓ Reviews anatomy, physiology
and the surgical procedures.
(they anticipate every move of
the dr, what instrument to give)
✓ Assists with the preparation of
the room.
✓ Scrubs, gowns and gloves self
and other members of the
Surgical team.
✓ Prepares the instrument table
and organizes sterile
equipment for functional use.
✓ Assists with the draping
procedure.
✓ Passes instruments to the
surgeon and assistants by
anticipating their need.
✓ Counts sponges, needles and
instruments.
✓ Monitor practices of aseptic
technique in self and others.
✓ Keeps track of irrigations used
for calculations of blood loss
Circulating ✓ Must be a registered nurse
Nurse who, after additional education,
(Circulator or specialized in perioperative
overseer) nursing practice.
✓ Responsible and accountable
for all activities occurring
during a surgical procedure
including the management of
personnel equipment, supplies
and the environment during a
surgical procedure. RUNNER
✓ Patient advocate, teacher,
research consumer, leader and
a role model.
✓ May be responsible for
monitoring the patient during
local procedures if a second
perioperative nurse is not
available.
Very defined ✓ Ensure all equipment is
activities during working properly. 100%
surgery: ✓ Guarantees sterility of
instruments and supplies.
✓ Assists with positioning.
✓ Monitor the room and team
members for breaks in the
sterile technique.
Pt is for biopsy. ✓ Handles specimens.
Specimen will be ✓ Coordinates activities with
obtain by other departments, such as
surgeon, given to radiology and pathology.
scrub nurse and ✓ Documents care provided.
then the ✓ Minimizes conversation and
circulating nurse. traffic within the operating
room suite.
Intraoperative Phase, Surgical Team, Positions during Surgery
Supine (Dorsal Recumbent)
Abdominal, extremity, vascular, chest, neck, facial, ear
breast surgery
Positioning ✓ Patient lies flat on back with arms
Techniques either extended on arm boards or
placed along side of body.
✓ Small padding placed under
patient’s head,neck and under
knees
✓ Vulnerable pressure points
should be padded.
✓ Safety strap applied 2 in. above
knees.
✓ Eyes should be protected by
using eye patch and ointment.
Prone Position
Surgeries involving posterior surface of the body
(spine, neck, buttocks and lower extremities)
Positioning ✓ Chest rolls or bolster are placed
Techniques on operating table prior to
positioning
✓ Foam head rest, head turned to
side or facing downward
✓ Patient’s arms are rotated to the
padded armboards that face
head, bringing them through their
normal range of motion.
✓ Padding for knees and pillow for
lower extremities to prevent toes
from touching mattress.
✓ Safety strap applied 2 in. above
the knees
Trendelenburg Position
Surgeries involving lower abdomen, pelvic organ when
there is a need to tilt abdominal viscera away from the
pelvic area.
Positioning ✓ Patient is supine with head lower
Techniques than feet.
✓ Shoulder braces should not be
used as they may cause damage
brachial plexus.
✓ When patient is returned to
supine position, care must be
taken move leg section slowly,
then the entire table to level
position.
✓ Modification of this position can
be used for hypovolemic shock.
✓ Extremity position and safety
strap are the same as for supine.
Reverse Trendelenburg Position
Upper abdominal, head, neck and facial surgery
Positioning ✓ Patient is supine with head higher
Techniques than feet.
✓ Small pillow under neck and
knees.
✓ Well - padded footboard should
be used to prevent slippage to
foot of the table.
✓ Anti embolic hose should be
used if position is to be
maintained for an extended
period of time.
✓ Patient should be returned slowly
to supine position.
Intraoperative Phase, Surgical Team, Positions during Surgery
Lithotomy Jack Knife Position
Perineal, vaginal, rectal surgeries; combined Rectal procedures, sigmoidoscopy and colonoscopy
abdominal vaginal procedure Positioning ✓ Table is flexed at center break
Positioning ✓ Patient is placed in supine Techniques ✓ All precautions taken with prone
Techniques position with buttocks near lower position are taken with Jack knife
break in the table ( sacrum are position.
should be well padded ) ✓ Table strap applied over thighs
✓ Feet are placed in stirrups,
stirrups height should not be
excessively high or low, but even
on both sides.
✓ Knee brace must not compress
vascular structures or nerves in
the popliteal space.
✓ Pressure from metal stirrups
against upper inner aspect of
thigh and calf should be avoided.
✓ Legs should be raised and
lowered slowly and
simultaneously (may require two Principles of Surgical Asepsis (Sterile Technique)
people ) ▪ Sterile object remains sterile only when touched by
another sterile object
▪ Only sterile objects may be placed on a sterile field
▪ A sterile object or field out of range of vision or an
object held below a person’s waist is contaminated
▪ When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field
becomes contaminated by capillary action
▪ Fluid flows in the direction of gravity
▪ The edges of a sterile field or container are
considered to be contaminated (1 inch)

Modified Fowler ( Sitting Position ) Common Surgical Incision

Otorhinology (ear and nose ), neurosurgery
Positioning ✓ Patient is supine, positioned over
Techniques the upper break in the table
✓ Backrest is elevated, knees
flexed
✓ Arms rest on pillow, placed in lap;
safety strap 2 in. above the
knees.
✓ Slow movement in and out of
position must be used to prevent
drastic changes in blood volume
movement.
✓ Anti embolic hose should be
used to assist venous return.
✓ When using special neurologic
headrest, eyes must be
protected.
Intraoperative Phase, Surgical Team, Positions during Surgery
ANESTHESIA Adjuncts to General Anesthesia
▪ State of “Narcosis” state of unconsciousness 1. HYPNOTICS
▪ Anesthetics can produce muscle relaxation, e.g., midazolam (Versed)., diazepam (Valium)
block transmission of pain nerve impulses and 2. OPIOID ANALGESICS
suppress reflexes. e.g, morphine sulphate, meperidine hydrochioride
▪ It can also temporary decrease memory (Demero), fentanyl citrate (Sublimaze)
retrieval and recall. 3. NEUROMUSCULAR BLOCKING AGENTS
➢ NON-DEPOLARIZING AGENTS
The effects of ✓ Respiration
pancuronium (Pavulon), atacurium (Tracium),
anesthesia are ✓ O2 saturation
vecuronium (Norcuron)
monitored by ✓ CO2 levels
➢ DEPOLARIZING AGENTS
considering the ✓ HR and BP
succinylcholine (Anectine)
following ✓ Urine output
parameters:
Adjuncts to General Anesthesia
▪ MALIGNANT HYPERTHERMIA
General Anesthesia Signs/Symptoms:
- reversible state consisting of complete loss of
tachycardia, dysthymias, muscle rigidity (especially
consciousness and sensation.
jaw and upper chest), hypotension, tachypnea,
- protective reflexes such as cough and gag are lost
cola-colored urine, extreme hyperthermia (latesign)
- provides analgesia, muscle relaxation and sedation.
- produces amnesia and hypnosis. Treatment: DANTROLENE (DANTRIUM)
▪ OVERDOSE
Techniques A. Intravenous Anesthesia ▪ COMPLICATIONS TO ANESTHETIC AGENTS
used in + This is being administered e.g., hypotension, bradycardia, dysthymias,
General intravenously and extremely rapid. respiratory depression, decreased seizure
Anesthesia + Its effect will immediately take place threshold
after thirty minutes of introduction. ▪ COMPLICATIONS OF ET INTUBATION
+ It prepares the client for smooth e.g., broken caps, teeth, swollen lip, trauma to the
transition to the surgical anesthesia. vocal cords, improper neck extension.

B. Inhalation Anesthesia
+ This comprises of volatile liquids or Spinal Anesthesia (Subarachnoid block)
gas and oxygen.
+ Administered through a mask or
endotracheal tube.
Stages of ▪ Stage 1: Onset / Induction.
General - Administration, conscious,
Anesthesia conversational.
▪ Stage 2: Excitement / Delirium.
- Reflexes kick in, increase vital
signs, don’t intubate
▪ Stage 3: Surgical
- Ideal state, can intubate
▪ Stage 4: Medullary / Stage of
Danger
- Overdose, can cause death

General Anesthesia Delivery Methods

Intraoperative Phase, Surgical Team, Positions during Surgery
Regional Anesthesia Complications and Discomforts of Anesthesia
- temporary interruption of the transmission of nerve Hypoventilation
impulses to & from specific area/region of the body. - inadequate ventilatory support after paralysis of
- achieved by injecting local anesthetics in close respiratory muscles.
proximity to appropriate nerves.
- reduce all painful sensation in one region of the Malignant Hyperthermia
body without inducing unconsciousness. - uncontrolled skeletal muscle contraction
- agents used are lidocaine and bupivacaine.
Hypotension
- due to preoperative hypovolemia or untoward
Techniques used in Regional Anesthesia reactions to anesthetic agents.
A. Topical Anesthesia
+ applied directly to the skin and mucous membrane, Cardiac Dysrhythmia
open skin surfaces, wounds and burns. - due to preexisting cardiovascular compromise,
+ readily absorbed and act rapidly electrolyte imbalance or untoward reaction to
+ used topical agents are lidocaine and benzocaine. anesthesia.

B. Spinal Anesthesia (Subarachnoid block) Hypothermia

+ local anesthetic is injected through lumbar puncture, - due to exposure to a cool ambient OR environment
and loss of thermoregulation capacity from
between L2 and S1
anesthesia.
+ agents used are procaine, tetracaine, lidocaine and
bupivacaine.
Peripheral Nerve Damage
+ anesthetic agent is injected into subarachnoid space
- due to improper positioning of patient or use of
surrounding the spinal cord. restraints.

*Low spinal, for perineal/rectal areas Nausea and Vomiting

*Mid spinal T10 ( below level of umbilicus) for hernia repair Oral Trauma
and appendectomy. Headache
*High spinal T4 ( nipple line ), for CS

C. Epidural Anesthesia Practice Question

+ achieved by injecting local anesthetic into epidural A female client, 23 years old was admitted for the first
space by way of a lumbar puncture. time at the QMMC, she was diagnosed to have
+ result similar to spinal analgesia ruptured appendicitis. She was scheduled to have
+ agents use are chloroprocaine, lidocaine and emergency Ex-Lap under general anesthesia.
bupivacaine. 1. Pre-op instructions to Answer:
the client would include the B. Explaining the procedure.
D. Peripheral Nerve Block following EXCEPT:
+ achieved by injecting a local anesthetic to anesthetize a. deep breathing and Rationale:
the surgical site. coughing exercise Explaining the treatment,
+ agents use are chloroprocaine, lidocaine and b. explaining the procedure procedure, and outcome is
bupivacaine. c. turning to the side done by the attending
d. foot and leg exercise physician
E. Intravenous Block (Beir block) 2. During the induction of Answer:
+ often used for arm, wrist and hand procedure anesthesia, what is your B.
+ an occlusion tourniquet is applied to the extremity to nursing priority action?
prevent infiltration and absorption of the injected IV agents a. secure informed consent Rationale:
beyond the involved extremity. b. maintain the OR room During the 1st stage of
quite and close the door general anesthesia (onset
F. Caudal Anesthesia c. stay with the patient and or Induction stage), noises
+ Is produced by injection of the local anesthetic into the assess for possible are exaggerated. For this
caudal/sacral canal anesthesia complication reason unnecessary noises
d. assist the physician in and motions are avoided.
G. Field Block Anesthesia preparing the OR table
+ The area proximal to a planned incision can be injected
and infiltrated with local anesthetic agents.