1. INTRAOPERATIVE PHASE/ PERIOD

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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. Monitoring intra operative complications
Body temperature – hypothermia
OT- cool level 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

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

15. 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.

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

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

26. 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.

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

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

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

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

31. 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

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

33. 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

34. 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