INTRAOPERATIVE PHASE/ PERIOD

Often called as operating room nursing Intra operative nurses see the client immediately before surgery and completes initial brief assessment

Maintaining safety and preventing injury Major consideration – safety Includes – Positioning Controlling equipment and supplies Maintaining surgical asepsis Monitoring the physiologic status Monitoring for potential emergencies

Position of the client Essential factors to consider in positioning a client are – The site of the operation The age and size of the client The type of anesthesia used Based on the pain site (eg- arthritis)

Dorsal recumbent or supine – hernia repair, mastectomy or bowel resection Trendelenberg – surgery of lower abdomen and pelvis Lithotomy – perineal and rectal areas, vaginal repair, D & C. Prone – cervical, spine, rectal, posterior leg Lateral – kidney, chest and hip

Positions Changes- Depending upon the type of surgery and visualization of the site Laser techniques, endoscopy or biopsy may require different client positioning Obese patient and operation table should withstand excess weight of the client Provide extra padding to assist skin integrity

Provide equipment safety Every articles in the operating room can be a source of injury – if not used properly So every action must be very carefully done

Counting surgical supplies and equipment (needle, sponges and instruments) Counts are performed by 2 nurses (before incision , during the surgery and immediately before the incision is closed) Final count is announced to the surgeon and charted in the intraoperative chart

Electrical safety All plugs and wires are inspected for correct attachment and working condition Check all equipments are in working condition or not Measures should take to prevent electrical burns

Maintain surgical asepsis All equipments must be sterile Sterile technique to minimize post op infection – by all members

Members of surgical team (surgeon, assistant, scrub personnel) must be in sterile area Circulating nurse is not sterile but monitor the sterile field – helps to maintain sterile technique of supplies and personnel

Assist with wound closure Surgical wounds may closed with sutures, staples or other materials or may be left open to heal by secondary intention. Drains The drain is chosen by surgeon and is based on the size of the wound and the type of the drainage expected Monitor the patency of drain and characteristics of pain even after transferring from OT

Monitoring intra operative complications Body temperature – hypothermia OT- cool level 60-75 degree f Humidity – 50-60% Provide appropriate covering Irrigation solution must be warmed to maintain body temperature Surgery for large body burns and infants surgery – 90 degree f

Nausea and vomiting Anaphylactic reaction Hypoxia and other respiratory complications Disseminated intravascular coagulopathy

Preparing to assist in an operation Perform surgical hand washing Do not touch anything that likely to be unsterile after scrubbing Gown – insert both hands simultaneously into the arms of the gown after opening it fully Ask the circulating nurse to tie it at the back Wear left glove then the right hand glove After this do not come in to contact with unsterile things including personnel, articles furniture and walls.

Inspect the instruments and other article on the trolley and make sure that all necessary things are there Count sponges and gauze pieces twice along with circulating nurse

Note the number of the articles on the black board and in the record /chart. Do this for all instruments too Special instruments should be find out from the surgeon (eg-retractors and other accessories, instruments, sutures, drains, catheters, etc)

Check OT table accessories are readily available Positioning self – mayo’s stand etc – easy reach to avoid coming in to contact with personnel who have not scrubbed

During surgery Be neat, careful and practical in performing Be alert and observant throughout the procedure and follow the steps carefully Be aware of the number of instruments, sponges, gauze pieces in use or discarded Handle all instruments with care – minimize injury to self and to the patient handover and receive the sharp instruments in container

See that drapes are firmly fixed with towel clips Fix a sterile screen to separate the anesthetists territory from the surgical field if possible Change gloves immediately if they become punctured or torn. Change drapes if they become wet Keep separate container to discard sponges, gauze pieces, blunt things and sharp things

After operation At the end of the procedure check the instruments and other utensils are properly used and replaces it to the containers. Take the help of circulating nurse for this and record everything See that all things such as the suction, diathermy etc have been switched off and disconnected before shifting the patient

Consult the anesthetist and obtain his permission before turning or shifting the patient Be present till the patient is safely transferred to the stretcher and moved out of the OR. RECORD all incidents and steps See that electrical gadget are switched off before leaving the theatre Report to senior incharge at the end of every operation

Any untoward incidents, injury, loss, breakage, damage and malfunction should be reported and recorded immediately Universal precautions are a must – reusable articles have been in contact with potentially infective material Gloves, syringes, catheters, needles and scalpel blades are meant for single use and must be discarded safely

See that OR is cleaned properly by the helper and kept ready quickly for the next case. Doubts and questions should can be clarify with the surgeon at the end.

An interested, dedicated, intelligent, cheerful and hardworking OT nurse be the best possible surgical assistant………………

Drains Drains are usually used when there is some body fluid, which need to be prevented from collecting. Fluids may accumulate as a results of various pathologies including ascites, peritonitis, abscess formation, hematoma and or from a surgical site.

Common types of drains Glove drain or penrose drain Used in superficial site eg:- surgical incision of superficial abscess

Corrugated rubber drain Used in deeper abscess cavities Eg- gluteal abscess, breast abscess etc

Tube suction drain Usually small caliber-romovac Connected to vacuum container Eg-intra abdominal collections, after thyroidectomy, mastectomy etc

Wider bore tube drain Used to drain bowel - gastrostomy, oesophagostomy or peritoneal or pleural cavity

Saratoga sump Suction tube drain which consist of 2 concentric tubes, the outer one of which has a side hole and the second one has multiple holes This is a variety of suction tube with does not get easily blocked by things like blood clots

Salem tube drain Used as an alternative to the Ryle’s tube for nasogastric drainage and feeding

T tube (kehr) T shaped tube which is used to drain the common bile duct after it has been opened and explored during surgery on the biliary duct

Jackson pratt drain It is having a bulb, a tube in which end is having several hole for drainage of fluid, a cap which is sealed and opened when the bulb is filled