Intraoperative care

Focus Topic: Intraoperative care

The intraoperative care period begins with the transfer of the patient to the operating room bed and ends with his admission to the PACU. No matter what kind of surgery your patient needs, he’ll receive an anesthetic during this time.

Anesthesia

To induce loss of the pain sensation, the anesthesiologist or nurse-anesthetist will use some form of anesthesia. (See Types of anesthesia.)

Types of anesthesia

Intraoperative care

 

What OR nurses do

Operating room responsibilities are divided between the scrub nurse and the circulating nurse. The scrub nurse scrubs before the operation, sets up the sterile table, prepares sutures and special equipment, and provides help to the surgeon and his assistants throughout the operation. The circulating nurse manages the operating room and monitors cleanliness, humidity, lighting, and safety of equipment. She also coordinates activities of operating room personnel, monitors aseptic practices, assists in monitoring the patient, and acts as a patient safety advocate.

Other nursing responsibilities during the intraoperative period may include positioning the patient, preparing the incision site, draping the patient, and documenting information (such as surgical team information, assessment, the care and handling of specimens, and the count sheet).

Time out for safety

Just before the procedure begins, the entire operative team stops and performs a final verification of the correct patient, procedure, and surgical site. Called a time out, this final step helps prevent serious errors from occurring.

Intraoperative care: Postoperative care

Focus Topic: Intraoperative care

The patient’s recovery from the anesthesia is monitored in the PACU. His ongoing recovery is managed on either an intensive care unit (ICU) or medical-surgical unit. The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon.

What the PACU nurse does

The postoperative period begins when the patient arrives in the PACU, accompanied by the anesthesiologist or nurse- anesthetist. The PACU nurse’s main goal is to meet the patient’s physical and emotional needs, thereby minimizing the development of postoperative complications. Such factors as pain, lack of oxygen, and sudden movement may threaten his physiologic equilibrium. Thanks to the use of short-acting anesthetics, the average PACU stay lasts less than 1 hour. The patient is assessed every 10 to 15 minutes initially and then as his condition warrants.

Discharge

Whether the patient is discharged from the PACU to the medical-surgical unit, the ICU, or to the short-procedure unit, safety remains the major consideration. The patient should:

  • demonstrate quiet and unlabored respirations
  • be awake or easily aroused to answer simple questions
  • have stable vital signs with a patent airway and spontaneous respirations
  • have a gag reflex
  • feel minimal pain
  • have return of movement and partial return of sensation to all anesthetized areas if a regional anesthetic was administered.

If the patient had major surgery or has a concurrent serious illness or if complications occurred during or immediately after surgery, he may be discharged to the ICU. Appropriate documentation should accompany the patient on discharge, according to facility policy.

Intraoperative care: Medical-surgical unit

Focus Topic: Intraoperative care

When assessing the patient after he returns to the medical-surgical unit, be systematic yet sensitive to his needs. Compare your findings with intraoperative and preoperative assessment findings, and report significant changes immediately.

Have a system

Follow a systematic approach to your physical assessment in order to make easier comparisons. Facilities typically have protocols for assessing patients postoperatively. Some facilities require assessments every 15 minutes until the patient stabilizes, every hour for the next 4 hours, and then every 4 hours after that.

Intraoperative care: Assessing postoperative status

Pay special attention to the patient’s breathing. Make sure the patient has a patent airway and check his respiratory rate, rhythm, and depth. Additional assessment measures include:

  • assessing the patient’s level of consciousness by testing his ability to follow commands
  • observing for tracheal deviation from the midline
  • noting chest symmetry, lung expansion, or use of accessory muscles
  • obtaining the patient’s blood pressure (systolic pressure shouldn’t vary more than 15% from the preoperative reading except in patients who experience preoperative hypotension)
  • taking the patient’s apical pulse rate for 1 minute and assessing the rate and quality of radial and pedal pulses, noting any dependent edema
  • taking the patient’s temperature, which may be low (due to slowing of basal metabolism associated with anesthesia or to the cold operating room or I.V. solution) or high (due to the body’s response to the trauma of surgery).

Encourage deep breathing to promote elimination of the anesthetic and optimal gas exchange and acid-base balance.

Encourage coughing if the patient has secretions. Excessive sedation from analgesics or a general anesthetic can cause respiratory depression. Respiratory depression can also occur if reversal agents wear off. (See Assessing for respiratory distress.)

Assessing for respiratory distress

Intraoperative care

 

Intraoperative care: Examining the surgical wound

When examining the surgical wound, follow the practitioner’s orders. Don’t remove dressings from a surgical wound without permission. Some dressings provide pressure to the wound; others keep skin grafts intact. If the dressing is stained by drainage, estimate the quantity and note its color and odor. Reinforce wet dressings with additional sterile dressings. If the patient has a drainage device, record the amount and color of drainage. Make sure the device is secure and free from kinks. If the patient has an ileostomy or colostomy, describe output. If the wound isn’t dressed, note the wound’s location and describe its length, width, and type (horizontal, transverse, or puncture). Describe the sutures, staples, or adhesive strips used to close the wound and assess approximation of wound edges.

Intraoperative care: Assessing the abdomen

When assessing the abdomen, first observe for changes in abdominal contour. Abdominal dressings, tubes, or other devices may distort this contour. To detect asymmetry, view the abdomen from the foot of the patient’s bed. Also, observe for Cullen’s sign, a bluish hue around the umbilicus that commonly accompanies intra-abdominal or peritoneal bleeding.

Auscultation station

Auscultate bowel sounds for at least 1 minute in each of the four quadrants. You probably won’t be able to detect bowel sounds for 6 hours or more after surgery because general anesthetics slow peristalsis. If the surgeon handled the patient’s intestines during surgery, bowel sounds will be absent even longer.

Patent patient

If the patient has a nasogastric tube, regularly check its patency. Confirm proper tube placement by checking the pH of gastric aspirate (normal pH is from 1 to 4), or by X-ray. Document findings for a baseline assessment and for future reference.

Intraoperative care: Providing comfort

The post-surgical patient may be unable to assume a comfortable position because of incisional pain, activity restrictions, immobilization devices, or an array of tubes and monitoring lines. Assess the patient’s pain by having him rate his pain on a scale of 0 to 10 (with 0 being no pain and 10 being the worst pain imaginable) and offer analgesics as ordered. Although most patients will tell you when they experience severe pain, some may suffer silently. Increased pulse rate and blood pressure may provide the only clues to their condition.

Support, promote, and discuss

Although emotional support can do much to relieve pain, it doesn’t replace adequate analgesia. Physical measures, such as positioning, back rubs, and creating a comfortable environment in the patient’s room, can also promote comfort and enhance the effectiveness of analgesics. (See Reducing pain after surgery.)

Discuss specific measures the patient can take to prevent or reduce incisional pain. (See Tips for reducing incisional pain.) Encourage the patient to request analgesics or use patient-controlled analgesia before pain is severe.

Reducing pain after surgery

Intraoperative care

 

Tips for reducing incisional pain

Intraoperative care

 

Intraoperative care: Recording intake and output

Measure postoperative intake of food and fluids, including ice chips, I.V. fluids, blood products, and irrigation fluid. Measure postoperative output of urine, tube drainage, and wound drainage.

Acting like an adult

An adult should have a minimum urine output of 0.5 to 1 ml/kg/hour. Report an output of less than 30 ml/hour for more than 2 consecutive hours. After surgery, the patient may have difficulty voiding; this occurs when medications, such as atropine, depress parasympathetic stimulation. In order to assess for catheterization, monitor the patient’s intake and palpate his bladder or use a bladder scanner regularly. Because some anesthetics slow peristalsis, the patient may not defecate until his bowel sounds return.

Ordinary output

When documenting output, note the source of output; its quantity, color, and consistency; and the duration over which the output occurred. Notify the practitioner of significant changes, such as a change in the color and consistency of nasogastric contents from dark green to “coffee grounds” or a larger volume of output than expected.

 

Intraoperative care: Postoperative complications

Focus Topic: Intraoperative care

After surgery, take steps to avoid complications. Be ready to recognize and manage them if they occur.

Intraoperative care: Reducing the risk of complications

To avoid extending the patient’s hospital stay and to speed his recovery, perform these measures to prevent postoperative complications.

Turn and reposition the patient

Turn and reposition the patient every 2 hours to promote circulation and reduce the risk of skin breakdown, especially over bony prominences. When the patient is in a lateral recumbent position, tuck pillows under bony prominences to reduce friction and promote comfort. Each time you turn the patient, carefully inspect the skin to detect redness or other signs of breakdown.

Don’t turn ’em all

Keep in mind that turning and repositioning may be contraindicated in some patients such as those who have undergone neurologic or musculoskeletal surgery that demands immobilization postoperatively.

Encourage coughing and deep breathing

Deep breathing promotes lung expansion, which helps clear anesthetics from the body. Coughing and deep breathing also lower the risk of pulmonary and fat emboli and of hypostatic pneumonia associated with secretion buildup in the airways.

Encourage the patient to deep-breathe and cough every hour while he’s awake. (Deep breathing doesn’t increase intracranial pressure.) Also, show him how to use an incentive spirometer. (See Using spirometers.)

Monitor nutrition and fluids

Adequate nutrition and fluid intake is essential to ensure proper hydration, promote healing, and provide energy to match the increased basal metabolism associated with surgery. If the patient has a protein deficiency or compromised immune function preoperatively, expect to deliver supplemental protein via parenteral nutrition to promote healing. If he has renal failure, this treatment would be contraindicated because his inability to break down protein could lead to dangerously high blood urea nitrogen levels.

Promote exercise and ambulation

Early postoperative exercise and ambulation can significantly reduce the risk of thromboembolism. They can also improve ventilation and brighten the patient’s outlook.

Passive, okay; active, better

Perform passive range-of-motion (ROM) exercises — better yet, encourage active ROM exercises — to prevent joint contractures and muscle atrophy and to promote circulation. These exercises can also help you assess the patient’s strength and tolerance.

Tolerance test

Before encouraging ambulation, have the patient sit and dangle his legs over the side of the bed and perform deep-breathing exercises. How well the patient tolerates this step is usually a key predictor of out-of-bed tolerance. Document frequency of movement, the patient’s tolerance, use of analgesics, and any other relevant information.

Intraoperative care: Detecting and managing complications

Despite your best efforts, complications sometimes occur. These may include atelectasis, pneumonia, and pulmonary embolism and thrombophlebitis. By knowing how to recognize and manage them, you can limit their effects. (See Detecting and managing postoperative complications.)

Using spirometers

Intraoperative careIntraoperative care

 

Detecting and managing postoperative complications

Intraoperative careIntraoperative careIntraoperative care

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Intraoperative care: Discharge planning

Focus Topic: Intraoperative care

Begin planning for the patient’s discharge at your first contact with him. Include his family or other caregivers in your planning to ensure proper home care. The discharge plan should include:

  • medication
  • diet
  • activity
  • home care procedures and referrals
  • potential complications
  • return appointments.

Problem potential

Recognizing potential problems early on will help your discharge plan succeed. The initial nursing history and preoperative assessment as well as subsequent assessments can provide useful information. Tailor the contents of your plan to the patient’s individual needs. Assess the strengths and limitations of the patient and his family. Consider several factors, including:

  • physiologic factors — general physical and functional abilities, current medications, and general nutritional status
  • psychological factors — self-concept, motivation, and learning abilities
  • social factors — duration of care needed, types of services available, and family involvement in the patient’s care

Can I get that in writing?

Provide written materials as a reference for the patient at home. Assess your patient’s reading and comprehension level and always make sure that readings are reinforced by personal teaching. Include information on these topics:

  • Medications—Teach the patient the purpose of drug therapy, proper dosages and routes, special instructions, potential adverse effects, and when to notify the practitioner. Try to establish a medication schedule that fits in with the patient’s lifestyle.
  • Diet—Teach the patient and, if appropriate, the family member or caregiver who will prepare his meals. Refer the patient to a dietitian i f appropriate.
  • Activity—After surgery, the patient is commonly advised not to lift a heavy weight such as a basket of laundry. Restrictions usually last 4 to 6 weeks after surgery. Let him know when he can return to work, drive, and resume sexual activity.
  • Home care procedures—After the patient watches you demonstrate a procedure, have him (or his caregiver) perform a return demonstration. If the patient needs to rent or purchase special equipment, such as a hospital bed or walker, give him a list of suppliers in the area.
  • Wound care—Teach the patient about changing his wound dressing. Tell him to keep the incision clean and dry, and teach proper hand-washing technique.
  • Potential complications—Make sure the patient can recognize signs and symptoms of wound infection and other potential complications, and provide this information in writing. Advise the patient to call the practitioner with any questions.
  • Return appointments—Stress the importance of the follow-up appointment in your teaching, and make sure the patient has the practitioner’s office telephone number. If the patient has no means of transportation, refer him to an appropriate community resource.
  • Referrals—Reassess whether the patient needs referral to a home care agency or other community resource. In some hospitals, the responsibility for making referrals falls to a home care coordinator, discharge planning nurse, or case manager.
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