CHAPTER

26
Intraoperative Nursing
Krista Brecht With contributions by:
Krisna Ogerio Jane Ashley
Donna Stanbridge Kathleen Osborn
Danielle Vigeant
Suzanne Watt

Outcome-Based Learning Objectives

After studying this chapter, the learner will be able to:
1. Discuss the sequence of events for the patient from the beginning of surgery to arrival in the postanesthesia care unit.
2. Differentiate the roles of the surgical team.
3. Describe the interplay between each team member in the success of the surgical intervention.
4. Prioritize nursing interventions to maximize patient safety in the operating room.
5. Evaluate effective nursing measures for patient advocacy in the operating room.
6. Prioritize the nursing care of patients experiencing selected intraoperative complications.
7. Differentiate the role of the certified nurse and the anesthesiologist for the anesthetized patient.

THE GOAL of perioperative or intraoperative nursing practice
is to assist patients and their families to achieve a level of well-
ness equal to or greater than that which they had prior to the
procedure (Association of periOperative Registered Nurses
[AORN], Perioperative Nursing Data Set (PNDS-2007). The
most important role of the perioperative nurse is to be a patient
advocate. The essence of the advocacy in the perioperative role
is defined as protection, communication (giving a voice), doing,
comfort, and caring.
Advocacy is described as an act of informing and supporting
the individuals so that they may make the best decisions possible
for themselves. It is also speaking up for someone who is unable to
speak for himself. Advocacy is a critical issue for surgical patients
who are unconscious or sedated and unable to make decisions re-
lated to their care. Protecting patients from harm is the essence of
the advocacy role of nurses, and it is a critical component for pa-
tients whose family members are not readily accessible and whose
only possible advocate is the nurse. This is often the case for the
patient having surgery. Many perioperative issues involve advo-
cacy. These may include helping patients who are uninformed or
have not given adequate consent for surgical procedures, con-
fronting an incompetent colleague, pressing for more analgesia for
618
a patient in pain, or supporting the patient’s view toward prolong-
ing life with extraordinary treatment or technology.
Surgical patients can be compromised by stress, disease
process, and sedation or general anesthesia, and they trust
that a perioperative nurse will advocate in their best interest
to ensure their privacy, dignity, rights, and safety.
The nurse must accept accountability for nursing actions that
safeguard the rights of the surgical patients. Perioperative nurses
act as patient advocates by protecting, and they must be able to
quickly and accurately identify advocacy issues and be ready to
intervene on behalf of their patients. In recent years, the accep-
tance of a conceptual model for patient care, published by
AORN, has helped to distinguish the relationship of various
components of nursing practice and the effect on patient out-
comes (Beyea, 2000) (Figure 26–1 䊏).
Guidance for Professional Practice
The practice of perioperative nursing is guided by its own pro-
fessional organization, the Association of periOperative Regis-
tered Nurses, as well as the Centers for Disease Control and
 CHAPTER 26 Intraoperative Nursing 619

a Joint Commission survey team at least every 3 years. A com-

plete discussion of the Joint Commission is presented in
Int Chapter 3 .

8
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FIGURE 26–1 䊏 Perioperative patient-focused model.
AORN (2008). The PNDS Model. Retrieved on July 2, 2008 from http://www.aorn.org/Practice
Resources/PNDSAndStandardizedPerioperativeRecord/PNDSModel/.
Prevention (CDC) and the Joint Commission. AORN defines its
mission as follows: “to promote safety and optimal outcomes for
patients undergoing operative and other invasive procedures by
providing practice support and professional development oppor-
tunities to perioperative nurses.” AORN is composed of approxi-
mately 41,000 perioperative registered nurses in the United States
and abroad who manage, teach, and practice perioperative nurs-
ing; who are enrolled in nursing education; and who are engaged
in perioperative research (AORN, 2007a). This professional orga-
nization has developed a conceptual framework and vocabulary
called the Perioperative Nursing Data Set (PNDS). The data set
addresses the domains of safety, physiological responses, behav-
ioral responses of the patient and family, and the environment of
the perioperative setting within the health system.
The CDC’s mission is to promote health and quality of life by
preventing and controlling disease, injury, and disability. It also
influences perioperative practice. In 1999, the CDC issued
guidelines for the prevention of surgical infection. Additionally,
it reflected the mission statement of the Joint Commission to
continuously improve the safety and quality of care provided to
er The surgeon heads the surgical team and is responsible for mak-
Int
ing decisions related to the surgical procedure. Depending on the
procedure, an assistant might be required. This assistant could be
another surgeon, physician, resident in a university teaching hos-
pital, or the registered nurse first assistant. The surgeon is respon-
sible for performing the procedure and for coordinating the team.
An expanded role for perioperative nurses is that of registered
nurse first assistant (RNFA). The RNFA collaborates with the
surgeon and performs the role of first assistant during the oper-
ation. This role includes handling tissue, providing exposure, us-
ing instruments, suturing the wound, and providing hemostasis.
The role of an RNFA is highly specialized and demanding. In
2008, AORN approved a policy statement that defines the RNFA
role, scope of practice, and qualifications.
Anesthesia Care Provider
The anesthesiologist is a health care provider who specializes in
the administration of anesthetic agents and provides care to alle-
viate pain and promote relaxation. This professional is responsi-
ble for maintaining the airway; monitoring and ensuring gas
exchanges, respiration, and circulation; estimating and replacing
blood and fluid losses; administering medications to maintain he-
modynamic stability; managing care in the event of a physiologi-
cal crisis; and constantly communicating with the surgical and
nursing team. The anesthesiologist heads the anesthesia team and
might be assisted by a respiratory therapist, anesthesia resident or
fellow in a university teaching hospital, or a certified registered
nurse anesthetist (CRNA). As Chapter 1 discussed, the CRNA
8

the public through the provision of health care accreditation
and related services that support performance improvement in
health care organizations (Joint Commission, 2007). The Joint
Commission is an independent, not-for-profit organization that
is the United States’ predominant accrediting body charged with
maintaining and improving health care delivery. The Joint
Commission’s comprehensive accreditation process evaluates
an organization’s compliance with its standards and other ac-
creditation requirements. Joint Commission accreditation is
recognized nationwide as a symbol of quality that reflects an or-
ganization’s commitment to meeting certain performance stan-
dards. To earn and maintain the Joint Commission’s Gold Seal
of Approval, an organization must undergo an on-site survey by
is an advance practice nurse, educated with a master’s degree from
an accredited nurse anesthesia educational program. CRNAs ad-
minister anesthesia and anesthesia-related care in four gen-
eral categories: (1) preanesthetic preparation and evaluation;
(2) anesthesia induction, maintenance, and emergence; (3) post-
anesthesia care; and (4) perianesthetic and clinical support func-
tions. The CRNA works under the supervision of the
anesthesiologist. In a large study examining morbidity associated
with anesthesia, researchers found several factors that signifi-
cantly reduce the risk of anesthesia. Among these are the direct
availability of an anesthesiologist during surgery, the presence of
a consistent anesthesia care provider throughout the case, and the
presence of an anesthetic nurse (Arbous et al., 2005).
 620 UNIT 5 Nursing Management of the Surgical Patient
Nurses
The perioperative nurse’s primary role in the operating room
(OR) is that of the circulating nurse. Most states have taken legisla-
tive measures in order to ensure the presence of a registered nurse
in the circulator role in the OR for every surgical procedure. The
circulating nurse’s duties are performed outside the sterile field
and encompass responsibilities of nursing care management
within the OR. The circulating nurse observes the surgical team
from a broad perspective and assists the team to create and main-
tain a safe, comfortable environment for surgery. The circulating
nurse communicates patient care needs to each member of the
surgical team, facilitating a united effort while being the patient
advocate whose actions are dedicated to ensuring that the patient’s
rights and wishes are respected and carried out.
The scrub nurse works directly with the surgeon within the
sterile field passing instruments, sponges, and other items
needed during the surgical procedure. The sterile field is the area
closely surrounding the OR table. Surgical team members who
work within the sterile field perform a surgical scrub of their
hands and arms with special disinfecting solution and, in addi-
tion to the regular surgical attire, don a sterile gown and gloves.
This role can also be performed by other personnel than an RN,
in which case the person is then called a scrub technician. Other
roles for RNs are team leader, assistant head nurse, head nurse or
nurse manager, nurse educator, and clinical nurse specialist.
As with any specialty, the perioperative nursing assessment is
the first step in providing individualized care for perioperative
patients. The nursing process serves as a guide to make perioper-
ative nursing assessments comprehensive and holistic in nature.
The focus is aimed at promoting and maintaining wellness as
well as identifying and preventing illness (Hurley & McAleavy,
2006). These assessments provide valuable information to the
entire perioperative team. The nursing care plans that are devel-
oped based on the assessment data are utilized to ensure conti-
nuity of care during each phase of the individual’s perioperative
experience. The assessment provides a baseline against which in-
formation about the individual’s stability can be measured and
monitored at any stage of her perioperative experience.
Perioperative Nursing Education
Given that most nursing programs offer limited or no operating
room experience in their curricula, nurses initiating a career in
the OR get their perioperative education either at the hiring in-
stitution or by enrolling in a postgraduate or fellowship periop-
erative program. It is estimated that a minimum of 3 to 6
months of instruction is required to adequately educate nurses
with no previous OR experience depending on the OR’s activi-
ties (AORN, 2007a). Programs may include the surgical envi-
ronment, aseptic technique, perioperative assessment,
anesthesia, positioning the surgical patient, sterilization and dis-
infection, surgical instruments, safety considerations, patient
teaching, teamwork, scrubbing and circulating, and wound
healing and hemostasis (AORN, 2007a). In addition to didactic
modules, nurses are often instructed through a cognitive ap-
prenticeship model in the OR in which they take on increasingly
complex responsibilities over time.
Health Promotion
Patient teaching for the intraoperative patient is usually done in
a preadmission testing clinic or the day before the surgery in a
patient general surgical unit. Once in the preoperative area, the
patient is normally anxious and stressed and assumes a passive
role as the recipient of technical care. The perioperative nurse
performs the preoperative assessment of patients in the holding
area. The responsibilities of the perioperative nurse in this set-
ting are to verify the appropriate data have been obtained, assess
the patient for readiness both physically and emotionally, and
reinforce teaching as needed. This information is the basis for
planning the patient’s individualized perioperative care.
The use of the nursing process emphasizes a patient-centered
approach; health promotion in the perioperative arena has be-
come more evident as perioperative nurses have gained great
satisfaction from knowing that they are part of a team commit-
ted to an individual patient with an individualized outcome. As
illustrated through the PNDS (p. 624), this framework enables
perioperative nurses to shift from a task-oriented role to that of
providing a holistic view of the patient. Therefore, even if the
nurse’s main role is still to ensure patient safety throughout a pa-
tient’s surgical experience, the nurse is now able to demonstrate
the caring aspect of perioperative nursing by participating in a
preoperative assessment of the patient.
Surgical Areas
Patients needing surgery go to the operating room for a surgical
procedure after having been admitted to the hospital on the same
day as surgery, unless an extensive work-up or in-hospital treat-
ments or tests are required prior to surgery. Patients also access the
operating room emergently through the emergency department.
The practice of same-day admission has become popular for both
financial reasons and because evidence suggests that surgical-site
infection rates are reduced when the preoperative stay is reduced
(Nichols, 2001).
Prior to being admitted to the surgical setting, the patient dons
a gown and cap. Surgical-site skin preparation includes a baseline
assessment, cleaning of the surgical site and surrounding area,
hair removal, and application of an antiseptic agent when re-
quired. Traditionally hair removal was extensive and often per-
formed the day prior to surgery. Research studies have revealed
that hair removal does not reduce the incidence of surgical-site
infections (SSIs). In fact, today, hair removal is instead performed
to improve access to surgical site, improve the field of view, or per
the institution’s policy or surgeon’s preference (Evidence-based
practice information sheets, 2003; Niel-Weise, Willie, & van den
Broek, 2005). Should hair removal be indicated, care needs to be
taken to maintain skin integrity and minimize injury. The re-
moval is ideally done outside of the surgical suite as close to the
surgery time as possible (AORN, 2007b). There is some evidence
that use of hair clippers is superior to use of a razor, but more re-
search is needed (Niel-Weise et al., 2005).
Presurgical or Preoperative Holding Area
The surgical area typically has a presurgical or preoperative
holding area next to the operating rooms. The preoperative
holding area is a semirestricted area usually just inside of the sur-
gical area. This area provides a quiet, calm transition area for the
patient to wait immediately before surgery. It provides a shield
from the sights and sounds of the busy surgical suite and allows
personnel to interview the patient and verify the documenta-

tion. Equipment should be readily available in the preoperative
holding area for patient care and monitoring. This includes oxy-
gen, suction, electrocardiogram machine, pulse oximetry, and a
blood pressure cuff; an emergency medical cart and defibrillator
should be nearby (Bailey, McVey, & Pevreal, 2005; Sullivan, 2000).
In the holding area, the nurse must verify that all the relevant
documents and studies (films, scans, etc.) are available prior to
the start of the procedure, that they have been reviewed and are
consistent with each other, and with the patient involved. Team
consensus about the intended patient, procedure, and site and as
applicable implant is also needed. This verification should occur
before the patient leaves the preoperative area and enters the
procedure/surgical room.
When the operating room suite is ready to receive the patient,
the patient is asked to empty the bladder to prevent incontinence
or overdistention because an overly full bladder can hinder access
to the surgical site and predispose the patient to inadvertent sur-
gical bladder injury. Urinary catheterization is performed in the
OR as necessary (Iorio et al., 2005). The nurse accompanies the
patient to the operating room where the patient will be placed on
the operating table and prepared for surgery.
Preoperative Operating Room Checklist
The preoperative checklist is a tool for continuing the patient as-
sessment. On it, allergies are documented as per facility policy.
Accurate documentation of height and weight is important for
proper dosage calculation of the anesthetic agents. The periop-
erative nurse ensures that the results of all laboratory, radi-
ographic, and diagnostic tests are on the patient’s chart.
Any abnormal results are documented and reported to the
surgical team as well as any special needs, concerns, or instruc-
tions especially with regard to cultural or spiritual beliefs, phys-
ical impairments or limitations, and psychosocial conditions.
For example, advise the surgical team whether the patient is a
member of Jehovah’s Witnesses and does not accept blood prod-
ucts or whether the patient is hard of hearing and does not have
his hearing aid (Hurley & McAleavy, 2006). Showing respect for
patients’ spiritual beliefs, psychosocial conditions, and physical
limitations facilitates rapport and trust that enable nurses to un-
derstand the important role these factors play in how people
cope with fear and anxiety related to their perceived periopera-
tive experience.
The perioperative nurse also notes the medical diagnosis,
previous surgical experience, patient’s physical appearance,
visual skin assessment, medical devices accompanying the pa-
tient or indwelling medical devices, and any prostheses, jewelry,
dentures, and/or capped teeth. The nurse also ensures that pre-
scribed preoperative medications have been taken by the patient
and any medications that have been ordered to be given just
prior to surgery such as antibiotics are documented on the chart
accompanying the patient. The NPO status of the patient is also
confirmed by the nurse to assess any potential risk of aspiration.
All relevant information is communicated to the surgical team.
Operating Room
Surgery may involve the removal, repair, drainage, replacement,
or exploration of body tissue or organs. The operating room or
suite is where the surgery will be performed. This room is a
restricted area where the team of health care professionals wears
CHAPTER 26 Intraoperative Nursing 621
attire that was donned in the surgery dressing room. This attire,
commonly referred to as “scrubs,” includes a shirt, trousers, cap,
shoe covers, and mask. Those directly involved in the surgical
procedure will have scrubbed and will be wearing sterile gowns.
Surgical hand preparation, previously known as a “surgical
scrub,” is performed prior to participating in a surgical procedure
in order to reduce the potential risk of SSI by reducing the num-
ber of microorganisms on intact skin of the hands and forearms.
Hand preparation considerations include use of a broad-
spectrum, fast-acting, nonirritating, FDA-approved antiseptic
agent. Traditional scrub techniques with prolonged use of deter-
gent, water, and brushes have contributed to the deterioration of
skin, sometimes leading to undesirable changes of hand skin
flora and colonization. Additionally, surgical facilities are exam-
ining ways to improve the use of physical resources and health
care professionals’ time. Compared to the traditional surgical
scrub, waterless hand preparation boasts a reduction in micro-
bial counts of hands, improved skin health, and reduced use of
time and resources (Larson et al., 2001). Below is a list of recom-
mended surgical hand preparation practices (AORN, 2007b),
and Chart 26–1 (p. 622) highlights the differences between a sur-
gical scrub and hand rub preparation method:
• Do not wear artificial nails.
• Keep skin free from open lesions and breaks.
• Remove all jewelry from hands and forearms before per-
forming hand hygiene.
• Use only lotions that are approved by infection control staff;
lotions must be compatible with the hand antiseptic and
gloves, and be stored in disposable, hands-free dispensers.
• Use a standardized hand scrub procedure that follows man-
ufacturer’s written guidelines and is approved by the health
care facility.
Due to the rapid growth of surgical technologies and innova-
tion during the past decade, many operating rooms have been
renovated or reconstructed. This has been done in part to ad-
dress the abundance of equipment needed in today’s operating
rooms as well as ergonomic issues. Recent trends in surgery in-
clude the move toward less invasive techniques with shorter hos-
pital stays and faster recovery periods. One of the newest trends
promising to transform surgery is the intelligent OR. The intel-
ligent OR incorporates advanced robotic surgical systems. A
speech recognition robot allows the surgeon to control the op-
erating bed, lighting, video displays, and other devices with sim-
ple voice commands. A robotic endoscopic camera facilitates
optimal views of the surgical field, and the robotic surgical assis-
tant enables the surgeon to control precise technical movements
of a robotic arm from a console station. Robotic systems are cur-
rently in use for certain cardiac procedures with plans for expan-
sion on the horizon. Surgical robots make it likely that future
surgeries could be performed at one facility with the surgeon
operating the console from a distant facility. One of the nurse’s
roles in robotic surgery is to assist the surgeon at the patient’s
side during the operation.
In addition digital information is becoming the standard
format for accessing patient information and images, for com-
municating with other areas of the hospital or consultants, and
for conferring with other health care providers. The operating
 622 UNIT 5 Nursing Management of the Surgical Patient
CHART 26–1 Traditional and Waterless Surgical Hand Preparation
Traditional Surgical Hand Preparation
1. Wash hands with soap and water.
2. Use a disposable nail cleaner to clean nail beds under running water.
Discard nail cleaner after use.
3. Rinse. Wash hands, then forearms, using antimicrobial-impregnated
sponge. Use the counted stroke technique or the recommended
amount of time according to the manufacturer’s instructions.
4. Rinse.
5. Proceed to operating room.
Note: Step 2 is performed for the first scrub of the day or as required.
Scrub time for step 3 may vary according to product instructions from
3 to 5 minutes.
room requires convenient real-time access to these digital data
and a way to manage the digital information acquired within
the operating room. OR design may be categorized into three
major areas: physical, information and communication sys-
tems, and management.
To accommodate an optimal workflow and facilitate obser-
vation of aseptic technique, certain physical considerations need
to be taken into account, including the dimensions of the OR
suite, positions of exits and entrances, and location of support
services. In addition, integration systems are available that per-
mit the control of medical devices, lighting, and the OR bed; ac-
cess to images; and the routing of all this digital information to
any particular monitor for display or to one or more recording
devices for archiving, or to pathologists or radiologists via tele-
conferencing links. Control can be maintained from the surgical
field by touch-screen or voice control interfaces, or from a nurs-
ing station (Figure 26–2 䊏).
Intentional OR design considers the logistics of flow, main-
tains versatility, optimizes the use of resources, promotes com-
munication, synchronizes services, and adopts technological
advances while including all stakeholders in order to promote
SDA Unit
Holding Area
Operating room
suite
Post Anesthesia
Care Unit
FIGURE 26–2 䊏 Layout of a typical surgical unit. (Note: SDA=Same
day surgery, DS=day surgery)
Waterless Surgical Hand Preparation
1. Wash hands with soap and water.
2. Use a disposable nail cleaner to clean nail beds under running water.
Discard nail cleaner after use.
3. Rinse and thoroughly dry hands and arms. Apply alcohol-based
surgical hand scrub product according to manufacturer’s instructions.
4. Proceed to operating room.
Note: Step 2 is performed for the first scrub of the day or as required. Hand preparation time
for step 3 generally requires 2 minutes.
successful adoption. The ultimate goal of surgical technology
adoption is to enhance patient care and improve patient out-
comes.
Surgical table setup is specific to the procedure, facility, and
surgeon preference. Scrub tables are often standardized in order
to facilitate efficiency and changeover of staff. Instruments vary
according to specialty and type of procedure. Figure 26–3 䊏 dis-
plays the contrast between traditional open surgery and endo-
scopic instrumentation.
Other perioperative nursing responsibilities include ensuring
proper instrument functionality intraoperatively through clean-
ing and inspection. Inadvertent patient injury may occur due to an
instrument malfunction, resulting in an undesirable effect such as
tearing tissue, loss of small parts inside the patient, or improper re-
processing leaving a residue of bioburden that can result in post-
operative complications. The use of protocols, checklists, and
detailed documentation of OR equipment is associated with a sig-
nificant decrease in perioperative patient injury (Arbous et al.,
2005). The majority of surgical instruments are composed of
high-grade stainless steel, although advances in surgery such as ro-
botics and minimally invasive surgery (MIS) have resulted in in-
DS
(a)
(b)
FIGURE 26–3 䊏 Surgical instruments : (A) traditional versus (B) endoscopic.
 CHAPTER 26 Intraoperative Nursing 623

novative discoveries of surgical materials and instruments. Surgi- concerns included performing surgery on larger patients and the
cal instruments are costly and require proper maintenance and spreading of cancer cells intraoperatively. The latter concerns have
care in order to preserve their longevity. been overcome through advances in equipment and instrumenta-
tion and adaptive surgical techniques that have enabled the use of
Patient Preparation laparoscopic gastric bypass surgery for bariatric patients. Study re-
ports confirm MIS to be oncologically safe (Bonjer et al., 2007).
Once they enter the surgical suite, patients are cared for by the
The laparoscopic cholecystectomy will be used to illustrate the dif-
anesthetist, surgeons, and nurses. Members of the team ask the
ferences between MIS and open surgery. Open surgery involves an
patient questions, apply electrocardiogram (ECG) leads, remove
incision under the rib cage on the right side of approximately 15
arms from gown, and so forth. Every effort should be made to
to 38 cm (6 to 15 in.) in order to allow surgeons access with their
limit activity with the patient until she has received a general
hands to perform surgery.
anesthetic or been given a relaxant if warranted. For example, a
Laparoscopic removal of the gallbladder involves several small
patient should have the bladder catheterized following the gen-
incisions, usually four, that are one-quarter to one-half inch in
eral anesthetic whenever possible. Also, patients should be kept
size. Trocars or ports (tubes with valves) are then inserted through
informed on an ongoing basis. This will prevent and limit anxi-
these small incisions in order to provide imaging through a tele-
eties created by the already stressful surgical experience. If re-
scope attached to a camera for viewing on a monitor while other
gional anesthesia is being used, the patient will remain awake;
ports are accessed for instruments used to perform the surgery. To
therefore, a screen is placed in front of the patient’s face. Seda-
provide space to view and perform surgery, the abdomen is in-
tives, hypnotics, or tranquilizers are administered in order to de-
flated with gas (usually carbon dioxide). Carbon dioxide is used
crease feelings of anxiety and provide sedation.
because it is readily accessible, inexpensive, does not support
The perioperative nurse greets the patient on arrival by first
combustion when using surgical energy sources, and is easily ab-
asking the patient his name and checks this with the patient’s
sorbed and excreted by the body through the circulatory and res-
identification bracelet, chart, and hospital card using at least two
piratory system. In addition, the smaller incisions available with
identifiers, for example, name and date of birth. The nurse re-
MIS require the use of finer instruments as shown in Figure
views the patient’s chart, the medical record, and preoperative
26–3b 䊏 (p. 622) resulting in less surgical trauma and immuno-
checklist, and ensures that the consent is signed and that all doc-
suppression than open surgery (Boo et al., 2007).
umentation, preoperative procedures, and orders have been
Advantages of a laparoscopic surgery over open surgery in-
completed. The nurse conducts the preanesthetic assessment by
clude less scarring, quicker recovery, shorter hospitalization,
looking at the patient from a holistic viewpoint. This means rec-
faster return to normal activities (work), fewer problems with
ognizing the individual person as a dynamic entity made up of
incisions, less pain, and less use of opioids, which reduces the
components that are continuously interacting with one another.
negative secondary effects associated with opioid use. Often pa-
The perioperative nursing assessment is the first step in provid-
tients undergoing laparoscopic surgery will be discharged the
ing individualized care to the perioperative patient. To harmo-
same day as surgery, whereas open surgery procedures can re-
nize care in all perioperative settings, the Perioperative Nursing
quire 3 to 5 days of hospitalization. The intraoperative cost of
Data Set vocabulary can be used as part of the data collection
MIS surgery is often more, but is offset by the reduced hospital
tool (Chart 26–2, p. 624). The PNDS describes the practice of
stay and quicker recovery (Noblett & Horgan, 2007).
perioperative nursing practice in four domains: safety, physio-
logical responses, behavioral responses, and health care systems. Many patients complain of discomfort similar to muscle ache
The first three domains reflect phenomena of concern to peri- in the shoulder area following laparoscopic surgery. This is a
operative nurses and are composed of nursing diagnoses, inter- referred pain and is due to the distention of the diaphragm,
ventions, and outcomes that surgical patients and their families which results from the insufflation of the abdomen with gas
that is required for laparoscopic procedures. The discomfort usually
experience. The fourth domain, the health care system, com-
subsides within 24 to 48 hours postoperatively.
prises structural data elements and focuses on clinical processes
and outcomes. The model is used to depict the relationship of
The Future of Surgery: Natural Orifice
nursing process components to the achievement of optimal pa-
Translumenal Endoscopic Surgery
tient outcomes (AORN, 2002).
Natural Orifice Translumenal Endoscopic Surgery (NOTES) is the
Comprehensively written nursing care plans have been
exploration of methods to perform surgery through any of the
specifically adapted to the perioperative environment as clinical
body’s natural orifices (e.g., oral, rectal, urethral, vaginal). NOTES
pathways. Because of the fast-paced environment of the OR, pa-
attempts to further minimize the effects of surgery through a to-
tients’ short lengths of stay, and the many routines, some proce-
tally noninvasive technique.
dures and protocols can be documented on a flow sheet.

Surgical Approaches Anesthesia

Minimally invasive surgery became widespread when the laparo-
scopic cholecystectomy became a standard of surgical care in the
early 1990s. Initial reservations included the limitations of equip-
ment, introduction of new instruments, and the ability of sur-
geons to adapt and acquire these new surgical skills. Other
Advances in anesthesia, such as improvements in airway devices,
use of quickly reversible inhalation agents, and selection of
short-acting anesthetic agents, have improved patient outcomes
(Arbous et al., 2005; Tarrac, 2006). Anesthesia needs to accom-
plish several things. It must produce sleep (hypnosis), lack of
624 UNIT 5 Nursing Management of the Surgical Patient

CHART 26–2 Perioperative Nursing Data Set

Code Diagnosis/Intervention/Outcome Yes No Comments

X29 Diagnosis: Risk of Injury related to transfer and transport
I26 Intervention: Confirms identity before the operative or invasive procedure.
I126 Intervention: Verifies operative procedure.
I60 Intervention: Identifies baseline tissue perfusion.
I65 Intervention: Identifies physiological barriers to communication.
I66 Intervention: Identifies physiological status.
I59 Intervention: Identifies baseline cardiac function.
I64 Intervention: Identifies physical alterations that may affect procedure-specific positioning.
Outcomes: Verbalizes comfort related to transfer/transport.
X4 Diagnosis: Risk for Anxiety related to knowledge deficit and stress of surgery
I13 Intervention: Assesses coping mechanisms based on psychological status.
I27 Intervention: Provides continuity of care.
I30 Intervention: Develops individualized plan of care.
I57 Intervention: Identifies and reports philosophical, cultural, and spiritual beliefs and values.
I85 Intervention: Minimizes the length of invasive procedure by planning care.
I101 Intervention: Provides care to each individual in a manner that preserves and protects the patient’s autonomy,
dignity, and human rights.
I106 Intervention: Provides instruction based on age and identified need.
I56 Intervention: Explains expected sequence of events.
I50 Intervention: Evaluates response to instructions.
Outcomes: Verbalizes/indicates decreased anxiety, ability to cope, understanding of procedure and sequence of
events. Questions answered.
X38 Diagnosis: Risk for Acute/Chronic Pain
I24 Intervention: Collaborates in initiating patient-controlled analgesia.
I51 Intervention: Evaluates response to medication.
I61 Intervention: Identifies cultural and value components related to pain.
I69 Intervention: Implements alternative methods of pain control.
I71 Intervention: Implements pain guidelines.
I108 Intervention: Provides pain management instructions.
I16 Intervention: Assesses pain control.
I54 Intervention: Evaluates response to pain management interventions.
Outcome: Demonstrates adequate pain management.
X28 Diagnosis: Risk for Infection
I3 Intervention: Administers care to invasive device sites.
I21 Intervention: Assesses susceptibility for infections.
I22 Intervention: Classifies surgical wound.
I94 Intervention: Performs skin preparation.
I31 Intervention: Dresses wound at completion of procedure.
Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross contamination.
X29 Diagnosis: Risk for Injury
I11 Intervention: Applies safety devices.
I39 Intervention: Evaluates for signs and symptoms of injury to skin and tissue.
I72 Intervention: Implements protective measures to prevent injury due to electrical sources.
I73 Intervention: Implements protective measures to prevent injury due to laser sources.
I77 Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical sources.
I93 Intervention: Performs required counts.
I84 Intervention: Manages specimen handling and disposition.
I112 Intervention: Records devices implanted during the operative or invasive procedure.
Outcome: Patient is free from signs and symptoms of physical injury.
X40 Diagnosis: Risk for Injury: Positioning
I38 Intervention: Applies safety devices.
I39 Intervention: Evaluates for signs and symptoms of injury to skin and tissue.
I77 Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical devices.
Outcome: Patient is free from signs and symptoms of physical injury.
 CHAPTER 26 Intraoperative Nursing 625

CHART 26–2 Perioperative Nursing Data Set—Continued

Code Diagnosis/Intervention/Outcome Yes No Comments

X30 Diagnosis: Deficient Knowledge
I19 Intervention: Assesses readiness to learn based on physiological status.
I20 Intervention: Assesses readiness to learn based on psychological status.
I79 Intervention: Includes family and support persons in the preoperative teaching.
I103 Intervention: Provides information and explains Patient Self-Determination Act.
I67 Intervention: Identifies psychological barriers to communication.
I63 Intervention: Identifies individual values and wishes concerning care.
I30 Intervention: Develops individualized plan of care.
I104 Intervention: Provides instruction about prescribed medications.
I105 Intervention: Provides instruction about wound healing and wound care.
Outcome: Patient demonstrates knowledge of the physiological responses to the operative or other invasive
procedure.
Association of periOperative Registered Nurses. (2002). PNDS Resources. AORN. Retrieved June 29, 2008 from http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/
PNDSResources/.

awareness and recall (amnesia), freedom from pain (analgesia),
and muscle relaxation. A variety of anesthetic agents can pro-
duce these effects. The anesthesia care provider considers the pa-
tient and selects the agent or a combination of agents that will
produce the best anesthesia with the fewest negative effects for
the patient.
Inhalation Agents
Inhalation agents are frequently used for anesthesia because
they are fast acting and easily controlled. Anesthetic agents pass
through a vaporizer and are mixed with oxygen. The patient in-
hales the vapors into the lungs. The gas crosses the alveolar
membrane, dissolves in the blood, and is carried to body tissues
via circulation where it attaches to receptor sites on the cells to
produce its effects, primarily depression of the central nervous
system (CNS). Frequently, a mixture of gases is used to maintain
anesthesia.
A number of theories have been proposed to explain how in-
haled anesthetic agents work, but no single theory explains the
various effects seen with these agents (Hoffer, 1999). The effects of
anesthesia diminish as the gas is washed out of the lungs with
100% oxygen and the remainder is metabolized by the liver. The
Pharmacology Summary box (p. 626) lists the advantages, the side
effects, and implications of commonly used anesthetic gases.
Intravenous Agents
A variety of intravenous (IV) agents are used to induce and
maintain anesthesia. The Pharmacology Summary box (p. 627)
lists common intravenous medications used for anesthesia or as
adjuncts to anesthesia. Induction of anesthesia may be accom-
plished with the administration of a sedative hypnotic or anxi-
olytic drug. Common drugs include barbiturates such as
thiopental sodium (Pentothal) and sodium methohexital
(Brevital). These drugs cause rapid, short-acting depression of
the CNS (sedative hypnotic), but they have limited analgesic ef-
fects. A smaller test dose is initially given to make sure the patient
tolerates the mediation without reaction. These drugs quickly
(within seconds) produce sedation and unconsciousness. Both
drugs can cause respiratory and cardiovascular depression.
Nonbarbiturate drugs that depress the CNS may also be used
to induce anesthesia. Etomidate (Amidate) produces rapid hyp-
nosis but with less effect on the respiratory and cardiovascular
systems than the barbiturate drugs. This makes it an attractive al-
ternative for use with high-risk patients. Etomidate suppresses
cortisol secretion causing hypotension. These effects are not sig-
nificant in short procedures but can be an issue in longer surger-
ies. Etomidate is used primarily in short procedures. Ketamine
hydrochloride (Ketalar) is a fast-acting CNS depressant that
causes profound anesthesia but little skeletal muscle relaxation. It
is associated with a difficult emergence phase that is characterized
by hallucinations and disassociative feelings (feeling separate
from the environment). The patient who is recovering from keta-
mine will do better in a quiet, supportive environment. Propofol
(Diprivan) is a rapid-acting hypnotic that causes minimal excita-
tion effects during induction. Risk of the patient’s vomiting or
thrashing during induction is reduced. A test dose is initially given
to test for allergy. Propofol is metabolized rapidly so it does not
accumulate in the blood when used to maintain anesthesia.
Patients emerge from propofol quite quickly during the recovery
period.
Other IV medications used in anesthesia include benzodi-
azepines and opioid analgesics. Examples of benzodiazepines
include midazolam (Versed), lorazepam (Ativan), and di-
azepam (Valium). The benzodiazepines are antianxiety agents
that also have hypnotic, sedative, and muscle relaxant effects.
Midazolam is sometimes used to induce anesthesia but these
drugs are more commonly used as premedication to reduce the
patient’s anxiety because they have an amnesic effect. Benzodi-
azepines are used in combination with other drugs to produce
conscious sedation or as adjuncts to regional anesthesia to
produce sedation and muscle relaxation. Opioids are used in
anesthesia for their analgesic effect. Common medications in-
clude morphine sulfate, fentanyl citrate (Sublimaze), sufen-
tanil, and alfentanil. Fentanyl is more potent than morphine
and is the most commonly used analgesic in anesthesia. The
opioid analgesics have good cardiovascular stability but cause
respiratory depression.
 626 UNIT 5 Nursing Management of the Surgical Patient

PHARMACOLOGY Summary of Anesthetic Gases Used During Surgery

Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility
Desflurane (Suprane) Maintenance of anesthesia. Very Must be heated to vaporize. Monitor for hypotension.
rapid emergence. Causes increase in heart rate and
Good degree of muscle relaxation. decrease in blood pressure.
Has a strong odor precluding its use
for induction of anesthesia. May
cause coughing if used for induction.
Enflurane (Ethrane) Maintenance of anesthesia. May lower the threshold for seizures. Monitor for hypotension.
Good degree of muscle relaxation. Increases heart rate and decreases Contraindicated in patients with
blood pressure. seizure disorders.
Halothane Maintenance of anesthesia. Rapid Fair degree of muscle relaxation. Can cause hypotension. Monitor for
(Fluothane) induction and emergence but less Increases heart rate and triggers premature ventricular contractions,
than that of isoflurane. arrhythmias. ventricular tachycardia, and ventricular
Low incidence of postoperative Requires a higher degree of liver fibrillation with use of epinephrine.
nausea and vomiting. metabolization than other agents. Provide warm blankets during recovery
Causes postoperative shivering. period.
Isoflurane (Forane) Induction and maintenance of Causes increase in heart rate and Monitor for hypotension.
anesthesia. Faster induction and hypotension. Hypotension can be
recovery than enflurane or unpredictable and severe if
halothane. concomitant use of antihypertensive
Minimal metabolization by the liver. agents.
Weak stimulation of secretions.
Nitrous oxide Rapid induction and recovery of Does not produce muscle relaxation.
anesthesia.
When used with other inhalants, it
reduces the concentration of other
agent.
Sevoflurane (Ultane) Induction and maintenance of
anesthesia. Very rapid induction and
recovery (3–4 minutes faster than
Isoflurane).
Minimal metabolization by the liver.
Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology of
the cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.
htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.
Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.

Muscle Relaxants
Muscle relaxants (neuromuscular blocking agents) primarily af-
fect skeletal muscle and they are used in surgery to facilitate en-
dotracheal intubation and to provide optimal operating
conditions. A rapid-acting neuromuscular blocking agent is ad-
ministered before intubation to paralyze the muscles of the jaw
and vocal cords making placement of the endotracheal tube eas-
ier. Muscle relaxation is used throughout the surgery to facilitate
dissection of tissue. During surgery, the anesthesia care provider
monitors the effects of muscle relaxant drugs with a peripheral
nerve stimulator. Recovery from neuromuscular blocking agents
after surgery is evidenced by the patient’s ability to breathe on her
own and hold her head upright as well as the presence of a strong
hand grasp. There are two types of neuromuscular blocking
agents, depolarizing and nondepolarizing.
Succinylcholine is a depolarizing agent and the only one in
clinical use. The drug has a strong affinity for acetylcholine recep-
tor sites and once it attaches to the site causes continuous depo-
larization of the motor end plate. Continuous muscle
contractions and fasciculations are followed by flaccid paralysis of
the muscles. The onset of paralysis is quick with intravenous ad-
ministration, 30 to 60 seconds, and the effects last up to 10 min-
utes. Often succinylcholine is used for intubation because it works
very quickly and wears off quickly, but there are disadvantages to
the drug. The depolarization of muscle cells causes a transient in-
crease in serum potassium that can produce cardiac dysrhythmia.
Muscle fasciculation (twitching) leads the patient to complain of
muscle soreness postoperatively. Succinylcholine is known to
trigger malignant hyperthermia in susceptible individuals. The
drug is broken down by the plasma enzyme cholinesterase. Pro-
longed paralysis occurs in individuals with insufficient amounts
of cholinesterase although this condition is rare.
Nondepolarizing agents work by blocking the depolarizing
action of acetylcholine at the motor end plate of the neuromus-
cular junction, thereby producing muscle paralysis. Muscle fasci-
culations do not occur with these drugs, eliminating
postoperative myalgia. Another advantage is that these agents
can be antagonized or reversed with the administration of
neostigmine, edrophonium, or pyridostigmine. Use of reversal
agents reduces the risk of morbidity associated with anesthesia

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia
Used During Surgery
Agent Action and Advantages
Intravenous Anesthetic
Etomidate (Amidate) CNS depressant used for induction
and maintenance of anesthesia for
short procedures. Hypnotic effect but
no analgesia.
Fewer respiratory and cardiovascular
effects than other agents.
Onset is 60 seconds with duration of
3–5 minutes.
Diazepam (Valium) Benzodiazepine with hypnotic and
amnesiac properties.
Used as adjunct drug in induction of
anesthesia and as a preoperative
medication to reduce anxiety.
Ketamine (Ketalar) CNS depressant used for induction of
anesthesia.
May supplement nitrous oxide
anesthesia.
Fewer postoperative nausea and
vomiting than other agents.
Midazolam (Versed) Benzodiazepine with hypnotic,
amnesiac, anxiolytic, and muscle
relaxant properties.
Used for induction of general
anesthesia and for conscious
sedation.
Propofol (Diprivan) CSN depressant used for induction
and maintenance of anesthesia.
Rapid onset with minimal excitation
during induction.
Sodium methohexital Barbiturate used for induction and
(Brevitol) maintenance of anesthesia.
More potent and with a shorter onset
and quicker recovery than
thiopental.
Thiopental sodium Barbiturate used for induction and
(Pentothal) maintenance of anesthesia.
Depresses CNS causing sedation and
hypnosis.
Ultrashort acting with onset in
10–20 seconds and duration of
20–30 minutes.
Opioid Analgesics
Alfentanil (Alfenta) Narcotic used for induction,
analgesia, and balanced anesthesia.
Rapid onset and short duration make
it a good choice for short surgical
procedures.
CHAPTER 26
Disadvantages and Side Effects
Suppresses cortisol secretion.
Postoperative nausea and vomiting.
May cause transient skeletal muscle
movements.
Metabolized in the liver.
May cause hypotension and
tachycardia.
Prolonged effect.
Increases salivary secretions.
Does not produce muscle relaxation.
May increase heart rate and blood
pressure.
Depresses respirations and increases
intracranial pressure.
Associated with emergence reactions
including hallucinations, dissociative
feelings, and irrational behavior.
Recovery can be prolonged.
Slower induction than with
barbiturates.
May cause hypotension and
tachycardia.
Abnormal muscle movement.
May cause hypotension.
May cause abnormal muscle
movements, coughing, and
laryngospasm.
Hypotension occurs in some patients.
Hiccups may persist postoperatively.
Depresses respiratory and circulatory
function.
Can cause anaphylaxis and
laryngospasm.
Metabolized by the liver.
Causes respiratory depression.
Can cause bradycardia and
hypotension.
Bradycardia is more likely in patients
who are taking a beta-blocking drug.
Nausea and vomiting common.
Intraoperative Nursing 627
Nursing Responsibility
Good anesthetic for patients with
asthma or cardiovascular disease.
Used in neurosurgery because it
causes a slight decrease in
intracranial pressure.
Monitor cortisol levels and blood
pressure.
Monitor sedation postoperatively.
Premedicate with anticholinergic
agent to reduce secretions.
Provide a quiet, calm, reassuring
environment for recovery.
Monitor heart rate and blood pressure.
Monitor airway to prevent aspiration.
Prepare patient for amnesia.
Monitor for respiratory depression.
Monitor blood pressure.
Cautious use in patients with allergies
to eggs.
Patient should be recumbent during
administration.
Monitor blood pressure.
Test dose given first.
Monitor vital signs.
Report bradycardia.
(continued)
628 UNIT 5 Nursing Management of the Surgical Patient

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia

Used During Surgery—Continued
Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility
Fentanyl Narcotic used as adjunct for induction Causes sedation and respiratory Monitor vital signs.
(Sublimaze) to anesthesia and for analgesia depression. Watch for signs of respiratory
supplement. May also cause bradycardia and depression.
The drug of choice for epidural hypotension.
analgesia.
Short acting.
Causes less nausea and vomiting
than morphine.
Morphine sulfate Narcotic used as premedication and Causes respiratory depression. Monitor vital signs.
for postoperative analgesia. Histamine release causes peripheral
Long-lasting effect. vasodilation and hypotension.
Nausea and vomiting common.
Sufentanil (Sufenta) Narcotic used for analgesic Prolonged respiratory depression. Monitor vital signs.
supplement in balanced anesthesia. Watch for signs of respiratory
More potent than fentanyl. Has a depression.
quicker onset and shorter recovery
than fentanyl.
Not associated with histamine release
so there is less hypotensive effect.
Depolarizing Muscle Relaxants
Succinylcholine Depolarizing neuroblocking agent Causes muscle fasciculations, Monitor vital signs.
with high affinity for acetylcholine bradycardia, and respiratory Maintain airway and clear secretions.
receptor sites. depression. Patient may complain of muscle
Produces muscle relaxation and May precipitate malignant soreness postoperatively.
paralysis. hyperthermia in susceptible
Used to facilitate endotracheal individuals.
intubation and to produce skeletal
muscle relaxation for short surgical
procedures.
Short-acting agent with onset in
30–60 seconds and duration of
several minutes.
Nondepolarizing Muscle Relaxants—Intermediate
Mivacurium Intermediate, nondepolarizing muscle Transient hypotension and Monitor vital signs.
(Mivacron) relaxant used for endotracheal bradycardia.
intubation and to produce relaxation Metabolized by plasma
of skeletal muscles for surgery. cholinesterase.
Effect lasts 15–20 minutes.
Vecuronium Intermediate, nondepolarizing muscle Metabolized by the liver. Monitor for delay of recovery
(Norcuron) relaxant used for endotracheal Causes respiratory depression. postoperatively.
intubation and to produce relaxation Minimal cardiovascular effects.
of skeletal muscles for surgery.
Effect lasts 20–40 minutes.
Nondepolarizing Muscle Relaxants—Long Acting
Tubocurarine Long-acting, nondepolarizing muscle Causes histamine release with Monitor blood pressure and airway
relaxant used for maintenance of hypotension. until full recovery from drug.
relaxation during surgery. Increases bronchial and salivary Observe for residual muscle
Muscle relaxant effects last 30–40 secretions. weakness.
minutes.
Metocurine Long-acting, nondepolarizing muscle Hypotension, increased salivary Monitor blood pressure and airway
(Metubine) relaxant used for maintenance of secretions, and respiratory until full recovery.
relaxation during surgery. depression. May take several hours for complete
Muscle relaxant effects last 30–90 neuromuscular recovery.
minutes.

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia
Used During Surgery—Continued
Agent Action and Advantages
Pancuronium Long-acting, nondepolarizing muscle
(Pavulon) relaxant used for maintenance of
relaxation during surgery.
Muscle relaxant effects last 30–60
minutes.
Anticholinergics
Atropine Anticholinergic agent used to
decrease salivary and respiratory
secretions, to treat bradycardia
and/or hypotension, and to reverse
muscle relaxants.
Glycopyrrolate Anticholinergic agent used to
(Robinul) decrease salivary and respiratory
secretions and to reverse
neuromuscular block.
Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology of
the cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.
htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.
Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.
(Arbous et al., 2005). Reversal drugs cause bradycardia, which is
treated with atropine or glycopyrrolate. Nondepolarizing agents
are divided into intermediate acting and long acting. Intermediate-
acting agents have a quick onset, 60 seconds or less, and last 25 to
40 minutes. Examples of intermediate-acting nondepolarizing
agents are vecuronium, atracurium, and mivacurium. Longer
acting nondepolarizing muscle relaxants also have a rapid onset
but last 45 to 60 minutes. Examples include pancuronium,
metocurine, and tubocurarine.
Complications of General Anesthesia
The majority of patients experience general anesthesia without
problems except for the complaint of a sore throat from the endo-
tracheal tube. Other problems that may occur with intubation are
damage to teeth or dental work and trauma to the vocal cords.
Complications that arise from general anesthesia include hypoxia,
hypotension, hypertension, cardiac dysrhythmia, residual muscle
paralysis, hypothermia, and malignant hyperthermia.
A drop in body temperature is common during surgery.
Anesthesia interferes with the physiological mechanisms of
thermoregulation. This effect combined with environmental
factors such as the ambient temperature in the OR, the exposure
of body cavities, and the administration of cold solutions (e.g.,
blood products, IV fluids) or irrigants leads to a reduction in
core body temperature. Studies show the most significant drop
in body temperature occurs during the first hour of anesthesia
(Hasankhani, Mohammadi, Moazzami, Mokhtari, & Nagh-
gizadh, 2007; Sessler & Todd, 2000; Wagner, 2006). Monitoring
body temperature and using warming devices during surgery
(e.g., blankets, thermal drapes, fluid warmers) is imperative
(Hasankhani et al., 2007; Wagner, 2006). Research supports the
use of forced-air warming blankets as the most effective method
of preventing or treating hypothermia (American Society of
CHAPTER 26 Intraoperative Nursing 629
Disadvantages and Side Effects Nursing Responsibility
Tachycardia, hypertension, and Monitor vital signs.
premature ventricular contractions.
Tachycardia, hypertension, urinary Monitor heart rate and blood pressure.
retention, and dry mouth. Heart rate is best indicator of
May cause cardiac arrhythmias. response to the drug.
Tachycardia, urinary retention, and dry Monitor heart rate.
mouth.
Fewer problems with cardiac
arrhythmias than atropine.
PeriAnesthesia Nurses, 2001). Some suggest that using a forced-
air warming blanket for 30 minutes prior to surgery helps pre-
vent intraoperative hypothermia and improve patient outcomes
(Bitner, Hilde, Hall, & Duvendack, 2007).
Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare but life-threatening
complication of anesthesia. The predisposition for MH is genet-
ically transmitted by an autosomal dominant trait. It is thought
that MH is triggered by the medications or agents used in gen-
eral anesthesia with the most common being succinylcholine or
one of the inhalant anesthetics. Other factors such as stress,
trauma, fatigue, or muscle injury may play a role in increasing
susceptibility to the condition or in modifying the patient’s re-
sponse to the condition. Malignant hyperthermia occurs most
commonly during induction of anesthesia although it may pre-
sent anytime during the surgery or early postoperative period.
Malignant hyperthermia is not well understood. With MH,
calcium levels within skeletal muscle cells increase, although the
reasons for this are not known. The elevation in intracellular
calcium activates muscle rigidity and spasm and a hypermeta-
bolic state. The increase in cellular metabolism leads to an in-
crease in carbon dioxide production (hypercarbia) and a
metabolic acidosis. As the process continues, the patient be-
comes hypoxic, hyperthermic, and develops dysrhythmias and
hypotension. Muscle breakdown with the release of myoglobins
leads to myoglobinuria and an increased risk of renal failure.
Damaged muscle cells release intracellular potassium and crea-
tinine phosphokinase (CPK) into the circulation.
The presentation of MH is variable. Early signs are masseter
spasm (contracture of jaw), sinus tachycardia, and an increase in
expiratory carbon dioxide levels. The anesthesia provider first
suspects MH by the rise in the patient’s expired CO2, which is
 630 UNIT 5 Nursing Management of the Surgical Patient
monitored throughout the surgery. An end-tidal carbon dioxide
level that is two to three times normal is the earliest and most de-
finitive sign of MH (Redmond, 2001). Other signs are rigor of
muscles, hypoxemia evidenced by a drop in oxygen saturation,
and tea-colored urine, indicating the presence of myoglobins.
Laboratory blood tests results show metabolic acidosis and in-
creases in serum calcium, potassium, and creatinine phosphoki-
nase. Hyperthermia is a late sign and temperature elevations can
be extreme with increases of 1 to 2 degrees every few minutes.
Other late signs are cardiac dysrhythmia and hypotension.
Malignant hyperthermia can be fatal. The key to treatment is
early recognition of the syndrome, immediate discontinuation
of the triggering agent, administration of dantrolene sodium to
produce muscle relaxation, and providing supportive care. Fol-
lowing emergency treatment, the patient is monitored in the in-
tensive care unit for 24 hours or longer because a small
percentage of patients experience a reoccurrence of MH (Red-
mond, 2001). Chart 26–3 summarizes the management of the
patient with malignant hyperthermia.
Other Complications
Other adverse events or complications may occur in the oper-
ating room as a result of the surgical procedure. Examples in-
clude such things as bleeding with excessive blood loss or
inadvertent injury to surrounding organs or tissues. Intraoper-
ative complication rates depend on the surgery, the type of
anesthesia, and the patient’s physical status. In studies of com-
plications associated with various procedures (e.g., abdominal,
spinal, orthopedic, and urologic), 3% to 4% of patients experi-
ence intraoperative complications (Rampersaud et al., 2006;
Tarrac, 2006).
Management of the Patient
CHART 26–3
with Malignant Hyperthermia
• Immediately discontinue triggering agent.
• Stop surgery if possible. Otherwise, deepen anesthesia with opioids,
sedatives, nondepolarizing muscle relaxants.
• Hyperventilate with 100% oxygen.
• Administer a bolus of dantrolene sodium (Dantrium) 2 to 3 mg/kg
intravenously with additional bolus doses up to 10 mg/kg until
decreased signs of hypercarbia.
• Administer cooling devices: Apply cooling blanket, use iced normal
saline intravenously, lavage open body cavities with iced saline.
• Hydrate with intravenous normal saline.
• Maintain a urine output greater than 2 mL/kg per hour. Administer
furosemide and/or mannitol if urine output is less than goal.
• Treat metabolic acidosis with intravenous sodium bicarbonate if it
does not self-correct with treatment.
• Treat hyperkalemia with intravenous sodium bicarbonate, 10 units of
regular insulin with dextrose intravenously.
• Treat cardiac arrhythmia if it does not self-correct with treatment. Do
not use calcium channel blockers.
• Continue to monitor vital signs, oxygen saturation, electrocardiogram,
urine output, arterial blood gases, and blood chemistry.
• Transfer to Intensive Care Unit for postoperative care.
Redman, M.C. (2007). Malignant hyperthermia: Perianesthesia recognition, treatment, and
care. Retrieved on July 2, 2008 from http://www.aspan.org/EdCeMalHyper.htm#head11.
Regional Anesthesia
Regional anesthesia is a general classification of anesthesia that
includes spinal and epidural anesthesia, peripheral nerve blocks,
Bier blocks, and local anesthesia. The common feature of all
types of regional anesthesia is the local injection of a medication
to block the transmission of sensory impulses from that area to
the brain, thus, effectively blocking the sensation of pain. Re-
gional anesthesia has some advantages over general anesthesia.
Usually, regional anesthesia does not depress respirations so the
patient is at lower risk of postoperative respiratory complica-
tions. This makes regional anesthesia a good choice for patients
with severe cardiopulmonary disease. Patients who receive a re-
gional anesthetic usually experience less postoperative nausea
and vomiting.
Regional anesthesia can be used for any number of surgeries.
It is commonly used for repair of inguinal hernia, transurethral
resection of the prostate, gynecologic procedures, and arthro-
scopies and other orthopedic surgeries including repair of hip
fractures in the elderly. Typically, patients scheduled for regional
anesthesia are premedicated in the holding area with an antianx-
iety agent to produce mild to moderate sedation. Opioid anal-
gesics may be administered to reduce the pain associated with the
insertion of needles and the administration of numbing agents.
Spinal Anesthesia
Spinal anesthesia, also called intrathecal anesthesia, is the injec-
tion of a local anesthetic into the subarachnoid space and directly
into the cerebrospinal fluid (CSF). The anesthetic blocks nerve
fibers (i.e., sensory, motor, and sympathetic) at the level of the
spinal cord. Spinal anesthesia effectively blocks motor and sen-
sory nerves so that the patient cannot move the affected area
(temporary paralysis) or feel pain, touch, temperature, or pres-
sure. The spinal needle is inserted between the 2nd and 3rd lum-
bar vertebrae (L2–L3) or the 3rd and 4th vertebrae (L3–L4). For
insertion, the patient is placed in a sitting position or in a side-
lying position with their head and knees flexed (i.e., fetal posi-
tion). A spinal needle is inserted in the intervertebral space
through the dura mater and into the subarachnoid space. Special
spinal needles called pencil point needles enter the dura mater by
separating the fibers rather than cutting them, reducing the risk
of a CSF leak after the needle is removed.
Commonly, spinal anesthesia includes the administration of
local anesthetics such as lidocaine, bupivacaine (Marcaine), or
chloroprocaine combined with an opioid analgesic such as fen-
tanyl or preservative-free morphine. The medication may be
mixed with a dextrose solution to create a hyperbaric solution
(i.e., a solution that is heavier than CSF). Once a hyperbaric so-
lution is injected into the CSF, it travels by gravity. The anesthe-
siologist may have the patient sit for a few minutes to create a
block in the lower extremities or place the patient supine with
the head tilted slightly downward to create a higher block. After
10 to 15 minutes, the block sets and does not extend further.
Epidural Anesthesia
Epidural anesthesia is the injection of a local anesthetic into the
epidural space. The epidural space is located adjacent to the
dura mater and contains fat, tissue, and blood vessels. Anesthetic
injected into the epidural space affects nerve roots as they leave
the spinal cord and some medication diffuses across the dura
mater into the subarachnoid space and the CSF. The anesthetic

spreads in both directions (i.e., cephalad and caudad) from the
site of the injection, and positioning has less effect on movement
of the medication than it does with spinal anesthesia.
The same medications used in spinal anesthesia are used in
epidural anesthesia, but the concentration of the drugs is greater
because they must diffuse across several layers of tissue. The on-
set of epidural anesthesia is slower than that of spinal anesthe-
sia. A test dose of lidocaine with epinephrine is injected to make
sure that the needle is correctly placed in the epidural space and
not in the subarachnoid space or in a vein. If the needle is mis-
takenly in a vein, the test dose produces transient tachycardia; if
it is in the subarachnoid space, it produces mild numbness. Fre-
quently, an epidural catheter remains in place after the opera-
tion to provide postoperative pain control. Caudal anesthesia is
the administration of a local anesthetic into the epidural space,
but the approach is through the caudal canal in the sacrum
rather than through the lumbar vertebrae.
Complications of Spinal or Epidural Anesthesia Spinal anesthesia
may be complicated by the development of headache, hypoten-
sion, and meningitis. Spinal headache or post–dural puncture
headache (PDPH) is a common postoperative complaint. PDPH
is caused by the leaking of CSF through the hole in the dura (e.g.,
the puncture site). The loss of CSF causes irritation of meningeal
nerves and vessels (Hyderally, 2002). Because PDPH develops or
worsens when the patient moves to an upright position, patients
may be restricted to bed rest for the first 8 to 24 hours postopera-
tively to reduce the incidence of spinal headache. When headache
develops, it is located in the occipital area and resolves in 1 to 3
days. Patients who develop a headache are treated with hydration
and analgesics. The patient is placed on bed rest with the head of
the bed maintained at less than 30 degrees to reduce CSF leak.
PDPH that does not resolve quickly or that produces an intolera-
ble headache may be treated with a “blood patch.” The anesthesi-
ologist injects 5 to 10 mL of autologous blood into the epidural
space at the site of puncture to seal the leak.
Whereas PDPH occurs postoperatively, hypotension is more
likely to occur while anesthesia is still being administered. Hy-
potension is caused by vasodilation associated with the blocking
of sympathetic nerves. When sympathetic nerves are blocked by
anesthesia, arteries and veins lose muscle tone and the ability to
constrict. This decreases venous return from the extremities and
reduces cardiac output. Hypotension can occur with both spinal
and epidural anesthesia. Hypotension is avoided with the admin-
istration of fluid volume usually normal saline. Medications with
strong alpha-adrenergic stimulation effects, such as ephedrine or
phenylephrine, are used to prevent or treat hypotension.
Spinal anesthesia is associated with a low risk of aseptic
meningitis. When it does occur, signs develop within the first 24
hours after surgery (Hyderally, 2002). The patient presents with
the typical signs of meningitis, fever, headache, nuchal rigidity,
and photophobia.
Peripheral Nerve Blocks
A peripheral nerve block is the injection of a local anesthetic
into or around a nerve plexus to produce anesthesia of a selected
area. The major advantage of a nerve block is that anesthesia is
confined to the area of the surgery and does not have a systemic
effect. Long-acting local anesthetics used in the nerve block pro-
vide extended control of pain postoperatively. The local anes-
CHAPTER 26 Intraoperative Nursing 631
thetic blocks motor, sensory, and sympathetic nerves. Fre-
quently, epinephrine is administered with the local anesthetic.
Epinephrine causes vasoconstriction of the area and decreases
vascular uptake of the medication, thus prolonging the effect of
the local anesthetic. The duration of the block depends on the
choice of anesthetic, the volume and concentration of the drug,
and the site being injected. Frequently, nerve blocks are admin-
istered by anesthesia in the holding area because they may take
anywhere from 5 to 30 minutes to take effect.
A nerve block can be performed in a number of different sites.
For example, an interscalene or axillary block of the brachial
plexus is done for surgeries on the shoulder, forearm, or elbow.
Surgery on the lower leg may be accomplished using a femoral or
sciatic block. Peripheral nerve blocks are used alone or in combi-
nation with general anesthesia. When used with general anesthe-
sia, the amount of general anesthesia can be reduced.
Complications that can occur with nerve blocks include
hematoma at the site of the block, nerve damage, and toxicity
from systemic absorption of local anesthetic. Other, specific com-
plications depend on the site where the block is administered.
Peripheral nerve blocks may be performed as outpatient sur-
geries. Patients are taught that recovery of motor function occurs
first followed by recovery of sensation. Note that while the area is
numb, the patient is at risk for inadvertently injuring the area.
A Bier block is a specific type of peripheral nerve block that is
administered intravenously, but certain techniques are used to
trap the anesthetic in the local area. Bier blocks may be used for
surgeries on an extremity, usually the arm. An IV catheter is in-
serted in the extremity at the most distal site possible. A pneumatic
tourniquet is applied proximal to the surgical site and inflated
higher than the patient’s systolic blood pressure. When the local
anesthetic (lidocaine) is injected intravenously, the obstruction of
blood by the tourniquet prevents it from leaving the surgical area.
At the completion of the surgery, the tourniquet is intermittently
deflated so that the lidocaine enters the patient’s general circula-
tion slowly, preventing a toxic reaction to the anesthetic.
Nursing Management
The verification process consists of information gathering and ver-
ification, which begins with the determination to do the procedure
and continues through all settings and interventions involved in
the preoperative preparation of the patient, up to and including
the time-out (discussed later) just before the start of the procedure.
Assessment
The nurse asks the patient to confirm the procedure to be com-
pleted, the surgical site, and the surgeon. The nurse verifies this
information with the surgical consent form, a site verification
form per organization policy, and the operating room schedule.
In some cases, especially when there is a left or right side in-
volved in the procedure, the correct area for surgery is marked
on the patient. Per the AORN (2008) correct site surgery posi-
tion statement, a comprehensive approach is needed in each
health care delivery system to prevent wrong site surgery. In
2003 AORN and the American College of Surgeons developed
national guidelines that are to be used with every patient having
surgery to eliminate inadvertently operating on the wrong sur-
gical site (see the National Guidelines box, p. 632).
 632 UNIT 5 Nursing Management of the Surgical Patient

NATIONAL GUIDELINES AORN Guidelines for Eliminating Wrong Site Surgery

The following guidelines are supported by both AORN and the American College of Surgeons.
1. Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient’s designated
representative if the patient is underage or unable to answer for him/herself.
2. Verify that the correct procedure is on the operating room schedule.
3. Verify with the patient or the patient’s designated representative the procedure that is expected to be performed, as well as the location of the
operation.
4. Confirm the consent form with the patient or the patient’s designated representative.
5. In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeon
should mark the site prior to giving the patient narcotics, sedation, or anesthesia.
6. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified for
each procedure that is planned to be performed.
7. Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.
8. Ensure that all relevant records and imaging studies are in the operating room.
9. If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.
10. In the event of a life- or limb-threatening situation, not all of these steps may be followed.

Source: Carney, B. Evolution of Wrong Site Surgery Prevention Strategies. AORN, Volume 83, Issue 5, pp. 1115–1122.

Nursing Diagnoses other implants, previous anesthesia/surgery history, artificial or

The actual and potential nursing diagnoses related to surgery loose teeth, previous surgery, comorbidities, particular patient re-
include: quests, or any other information deemed crucial to intraoperative
patient care. Although this verification takes place in the same-day
1. Stress, Overload admission unit or the surgical unit, many ORs have developed a
2. Surgical Recovery Delayed presurgical checklist to ensure that all pertinent information is re-
3. Fear viewed and communicated.
4. Infection, Risk for
5. Pain, Acute. Preventing Wrong Site Surgery
When a procedure involves a left/right distinction, multiple
Planning structures (such as finger and toes), or multiple levels (such as
To provide the safest and least stressful experience for the patient, spinal procedures), the intended site must be marked so that the
planning is essential. Planning for the surgical experience typically mark will be visible after the patient has been prepped and
begins with the admission to the hospital. A comprehensive plan draped. The purpose is to identify unambiguously the intended
that organizes the care of the patient and family will facilitate the site of incision or insertion. The mark must be made using a
surgical process. The plan includes preoperative, intraoperative, marker that is sufficiently permanent to remain visible after the
and postoperative management and teaching. Communication is skin preparation. The Joint Commission (2004) recommends
as essential part of executing the plan. Each hospital has specific that the method and the type of marking should be consistent
forms that are used to guide the nurse through the process. throughout the organization and that the person doing the
Chapter 25 includes an example of a preoperative checklist. marking should be the one doing the procedure. Marking must
8

take place with the patient involved and aware.

Outcomes and Evaluation Parameters
The desired outcome for patients having surgery is that the pa-
tient safely transitions through the entire process. Evaluation pa-
rameters include: airway is maintained, oxygen levels are within
normal limits, pain is managed and any postoperative complica-
tions are effectively mitigated or controlled as much as possible.
Interventions and Rationales
The nurse must communicate pertinent information to the anes-
thesia team. Information may include allergies, lab/test results,
skin condition, NPO status, sensory/mobility impairments, phys-
ical particularities, restrictions to jaw and neck range of motion,
history of drug use including herbal medication, anticoagulants
held for number of days, implanted electronic devices (IEDs),
Exemptions to the marking procedure may include single-
organ cases, interventional cases where the point of insertion
is not predetermined (such as cardiac catheterization), teeth
extractions (although the involved tooth should be
documented), and premature infants, for whom the mark may cause a
permanent tattoo.
As the patient’s advocate, the perioperative nurse should com-
municate with all members of the surgical team to verify the cor-
rect surgical site. Individual facility policy should clearly delineate
the role and responsibility of the health care provider and other
team members in marking and verifying the correct surgical site.
The 2006 statistics on sentinel events from the Joint Commission
identify wrong site surgery as the second most reported sentinel
event, accounting for 13% of reported sentinel events (Beyea,

2000). Although it is the surgeon’s role to diagnose a patient’s need
for surgery and to delineate the surgical site, verifying the surgical
site at the time of surgery is the responsibility of perioperative
nurses and every member of the health care team (AORN, 2008).
To this effect, the Joint Commission has issued regulations and is
endorsing the Universal Protocol as part of the 2007 National Pa-
tient Safety Goals (Joint Commission, 2007).
The goal of the universal protocol is to prevent wrong site,
wrong procedure, and wrong person surgery. The Joint
Commission’s national guidelines to prevent wrong site
surgery are based on the consensus of experts from the
relevant clinical specialties and professional disciplines and is endorsed by
more than 40 professional medical associations and organizations. The
active involvement of the team and the patient or patient’s representative
and effective communication among all members of the operating room
team are important for success.
Guidelines for Implementing JCAHO Universal Protocol
To Promote Correct Site Surgery
PREOPERATIVE VERIFICATION
2 Patient Identifiers Must be Used (for example)*
• Ask patient to state their full name.
• Ask patient to state their date of birth.
• Ask patient to state their planned procedure and
document it in the patient’s own words.
• The patient’s room number is not an acceptable patient identifier:
Confirm and Verify
• Patient’s name on their ID band, date of birth, and other
documents that correspond with the patient’s responses.
• Medical record number.
• Consents.
• Availability of implant if required.
• Availability of blood if ordered.
• Radiologic exams (x-ray, CT scan, MRI, etc.).
PATIENT RESPONSES MUST MATCH:
MARKED SITE * ID BAND * CONSENTS * RADIOLOGIC EXAMS *
SCHEDULED PROCEDURE
In the case of pediatric patients and patients unable to verify
information for themselves, the RN identifies the patient’s
legal guardian and verifies with them the following protocol.
SITE MARK:
• Use a permanent marker that is visible after skin is prepped and draped
• Have operating physician/surgeon mark the site with his or her initials,
prior to patient entering the OR suite. ***
• Mark site(s) with patient participation (e.g., verbal confirmation or
visual pointing).
• Use an additional mechanism for identifying site(s) exempt from
marking according to facility policy and JCAHO guidelines (For
example, an ID band with the procedure written on it is an alternative
for site marking. When possible the ID band should be verified during
the time out phase similar to the site mark).
FIGURE 26–4 䊏 AORN guidelines for verifying the correct surgical site.
AORN. (2008). AORN position statement. Retrieved on July 2, 2008 from http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurgery/.
CHAPTER 26 Intraoperative Nursing 633
Surgical Time-Out
Safety initiatives that address communication issues such as the
time-out are designed to promote correct site surgery. The time-
out checklist has been adopted from the aviation industry
model and requires surgical team members to cease all other ac-
tivities in order to actively, verbally, and mutually verify infor-
mation such as the correct patient, correct surgery, correct
site/side, correct patient position, and possibly additional infor-
mation such as prophylactic medications being administered at
the appropriate time prior to surgery. Figure 26–4 䊏 shows a
sample of a time-out checklist.
Wrong site surgery may be the result of operating on the wrong
patient or performing the wrong procedure, but most commonly
it is the result of operating on the wrong site/side; for example, the
left hand is operated on instead of the right (Joint Commission,
2007). Although rare, the consequences of wrong site surgery can
When marking the site
DO NOT USE:
The letter X or the word NO
Do NOT mark the Non-Operative Site
According to AORN standards, the patient is
identified by the circulating RN when the patient
enters the OR suite. The procedure and surgical site
are validated at this time as well.
“TIME OUT”
Takes place in the procedure/OR room, after the patient is
prepped and draped and it involves the ENTIRE TEAM.
All team members must verbally verify their agreement on:
• The name of the patient.
• The procedure to be performed.
• The site of the procedure, including laterality, implant to be used
and radiologic exams, if applicable.
Validate site mark after draping or confirm ID band with the
procedure written on it if used in cases of exemption.
DISCREPANCIES/ISSUES
Procedure does not start until patient verification & missing
information is completed and agreed upon by all team members.
If a disagreement is not resolved, follow your facility policy and
notify your manager or administrator.
All issues resolved are documented in the medical record.
DOCUMENTATION of “TIME OUT”
Should indicate the following was verified:
• Correct patient.
• Correct site and side.
• Agreement to procedure.
• Correct patient position.
• Implants and/or special equipment or special requirements available.
* Facility determined identifiers should be used.
** Remove the mark at the end of procedure, especially for
patients returning for subsequent procedures (e.g., trauma).
*** If operating physician does not mark site, an individual identified
by facility policy with knowledge of the patient and planned
procedure to be performed may mark the site.
 634 UNIT 5 Nursing Management of the Surgical Patient

AORN SAMPLE Patient Record Addressograph

(Facility Name and Address)
This record is a sample only. Clinical records should be customized to
incorporate data fields that represent the setting, facility, procedure, and patient. (Patient Information:
Reproductions and variations are encouraged, provided credit is given to AORN. name, age, gender, medical record number, date)

Structural Data:
Operating Room Progress Notes Surgeon 1: Circulating nurse 1:

Room #: ASA: Pt. in room: Anes. start:

Surgeon 2: Circulating nurse 2:

Procedure start: Procedure finish: Pt. out of room: Anes. finish:

Assistant 1: Circ. 1 relief:

Time in: Time out:

Anesthesia type:
Assistant 2: Circ. 2 relief:
General MAC Spinal Epidural
Time in: Time out:
Local block, Type: Other:
Anesthesia care provider 1: Scrub 1:

Op Dx:
Anesthesia care provider 2: Scrub 2:

Procedure(s):
Laser operator: Scrub 1 relief:

Time in: Time out:

Op Dx:
Other authorized personnel: Scrub 2 relief:

Time in: Time out:

Nursing Data Elements - Preoperative:
Preoperative checklist reviewed/evaluated Risk for anxiety related to knowledge deficit and
Risk for injury related to transfer and transport (X29): stress of surgery (X4):
ID confirmed Consent verified Site verified Psychosocial status:
Allergies verified Procedure verified Calm/relaxed Anxious Talkative
Latex allergy: Yes No NPO verified Crying Restless
Time: Other:
Alert/oriented Drowsy Sedated Provided instruction based on age and identified
Asleep Unresponsive Disoriented needs (I106).
Other: Communicated patient concerns to appropriate
members of health care team (I128).
Cool Warm Intact
Dry Moist Body jewelry removed Explained sequence of events and preoperative
Tattoos: routine (I56).
Evaluated response to instructions (I50).
Sensory impairment: No limitations Hearing
Language barrier Sight Risk for acute/chronic pain (X38, X74):
Instructed on use of pain scale
Musculoskeletal status: No limitations Paralysis Traction
Pain assessment (0-10):
Prosthetics/Assistive devices: Hearing aid Glasses Location:
AICD Outcomes:
Prosthetics:
Verbalizes/indicates decreased anxiety, ability to
cope, understanding of procedure and sequence of
Cardiopulmonary status:
events. Questions answered.
Peripheral edema: Yes Location:
Demonstrates adequate pain management.
No
Verbalizes comfort related to transfer/transport.
Transfer to suite via:
DVT/PE risk: High Med. Low
Respiratory: Tracheotomy Intubated Chest tube Stretcher W/C Bed
Regular Labored Other findings Isolette Crib

FIGURE 26–5 䊏 Sample of intraoperative nursing documentation.

 CHAPTER 26 Intraoperative Nursing 635

Intraoperative Structural Data:

EKG Oximeter NIAPB Temp monitor OR medications: (other than those given by anesthesia care provider)
Implants/Prosthesis: Yes No Exp. Date: Time Medication Dosage Route Initials
Manufacturer:
Type:
Size:
Lot/Serial #:
Blood products: Yes No Blood band #: X-rays: Yes No Pathology specimens:
Unit #: Start time: Finish time: Site: Routine: Yes No
Unit #: Start time: Finish time: #:
Type:
Unit #: Start time: Finish time: Protective devices: Frozen section: Yes No
#:
Blood recovery: Yes No Unit #: Gonadal Thyroid
Cultures: Yes No
CCs reinfused: Other:
#:
Irrigation: Grafts: Yes No Comments:
Type:
Type:
Donor site:
Amount: Recipient site:

Intraoperative Nursing Data:

Risk for infection (X28): Risk for impaired skin integrity (X50):
Skin Pre-op intact Other: Position for surgery: Supine Prone Mod. lithotomy Jackknife
Surgical clippers: Lt. lateral Rt. lateral Other:
Area: Positioning devices: Chest roll Shoulder roll Axillary roll
Skin prep By: Pillow/wedge Stirrups Leg holder
Povidone-iodine Chlorhexidine
Other: Pad bony prominences: Elbows Heels Arms tucked/padded
Other:
Wound classification:
Positioned by:
1-Clean 3-Contaminated
2-Clean/contaminated 4-Dirty Risk for injury (X29):
Apply safety strap to:
Urinary catheter:
Apply grounding pad Site:
(size/type/site):
Electrosurgical unit #: Bipolar #:
OR output: Inserted by:
Setting: Coag: Cut:
Drains/tubes (size/type/site): Laser Type: Unit #: Settings: Time:
OR drainage amount: Safety measures implemented Operator:
Packing (size/type/site): Tourniquet checked & applied #: Site: Applied by:
Cast (type/site):
Inflated: Deflated: Pressure:
Dressing (type/site):
Sequential stockings: Yes No Other: Unit #:
Risk for hypothermia (X26): Counts: Sponge Needles Instruments
Apply warming blanket #: 1st count: Correct Correct Correct
Temp setting: 2nd count: Correct Correct Correct
Applied by: 3rd count: Correct Correct Correct
Unresolved Unresolved Unresolved
Warm IV fluid
N/A N/A N/A
Warm irrigation
Other: Surgeon notified of counts If counts unresolved, X-ray taken: Yes No
Signature: If no, explain:
Postprocedure Assessment/Evaluation:
Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination (O10).
Skin remains smooth, intact, non-reddened, non-irritated, free of bruising (O5, O2, O8).
Core body temperature remains in expected range (O12).

be devastating and warrant improved systems that promote effec-
tive communication such as the time-out initiative.
Intraoperative Patient Record
Most facilities have an intraoperative patient record, like that
shown in Figure 26–5 䊏, that is used to record intraoperative in-
formation. In addition, perioperative nurses may chart informa-
tion in the nurse’s notes when warranted. For example,
information may include personnel involved, length of surgery,
position and accessories implemented, wound classification,
anesthesia classification, and monitoring devices to name a few.
Protecting the Patient from Infection
Surgical-site infections are the third most frequently reported
type of iatrogenic (hospital-acquired) infection (Engemann et
al., 2003). Preventing and minimizing associated risks of SSI are
fundamental perioperative nursing diagnoses of the surgical pa-
tient. According to Nichols (2001), the most critical factor in
 636 UNIT 5 Nursing Management of the Surgical Patient

postoperative infection is the sound judgment and proper prac- in aseptic technique, and to correct any violation whether or not
tice of the surgical team in addition to the general health and anyone else is present or observes the violation. A surgical con-
disease state of the patient. It is for this reason that perioperative science mandates a commitment to aseptic practice at all times”
nurses have become quite expert in the areas of aseptic tech- (Spry, 2005). This allows personnel to function in a more efficient
nique and sterile conscience. Surgical aseptic practice is based and safe manner.
on the premise that most infections are caused by exogenous or- One of the strategies employed is the creation of the sterile
ganisms or organisms that are external from the body. field. The sterile field begins at the surgical site (incision), and
Asepsis is the absence of infectious organisms. In the OR asep- extends to the rest of the patient, OR table, surgical team, scrub
tic techniques are practices that minimize contamination due to table, and to a 1-foot parameter around the draped areas (Figure
microorganisms. Frequently aseptic techniques and practices 26–6 䊏). This principle is applied to application of prepping so-
are criticized for being ritualistic in nature and lacking in scien- lutions, patient draping, room setup, and so forth. It is com-
tific rigor, but until empiric evidence demonstrates a technique monly referred to as the clean to dirty principle.
is otherwise unnecessary or ineffective, basic aseptic principles Surgical attire, scrubbing, gowning, and gloving are all func-
should be observed. tions of OR aseptic technique. Figure 26–7 䊏 shows a nurse in
There are no sterilization processes that completely eliminate
all microorganisms. The best technologies to date can only limit
and reduce the presence of microbial life such as bacteria,
viruses, fungi, and spores to an acceptable sterility assurance
level. It is for this reason that nurses and surgical team members
in the OR need to continually monitor the surgical field and de-
velop strategies to minimize patient risk. An example may in-
clude inspecting sterile packaging, delivering items using proper
aseptic technique, and ensuring items have been appropriately
sterilized.
SSIs may also be predicted based on the surgical wound clas-
sification. The CDC publishes norms for SSI rates based on cer-
tain indicators, including wound classification (see the National
Guidelines box). The CDC data provide benchmarks for health
care professionals to evaluate their SSI rates so they can further
investigate the problem and implement initiatives should the
rates be unusually high.
The purpose of surgical wound classification is to track and
learn the cause of infections in order to prevent future
incidence. This information is generally recorded on the
patient’s intraoperative record.
Over time, surgical team members will in fact develop a surgi-
cal conscience. Surgical conscience is defined as “An inner com-
mitment to strictly adhere to aseptic practice, to report any break FIGURE 26–6 䊏 OR table.

NATIONAL GUIDELINES for Surgical Wound Classification

Clean wounds An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or
uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained
with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in
this category if they meet the criteria.
Clean-contaminated wounds Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled
conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina,
and oropharynx are included in this category provided no evidence of infection or major break in technique is
encountered.
Contaminated wounds Includes open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open
cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent
inflammation is encountered are included in this category.
Dirty or infected wounds Includes old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or
perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the
operative field before the operation.
Source: Devaney, L., & Rowell K. S. (2004). Improving surgical wound classification—why it matters. AORN Journal. Retrieved on July 2, 2008 from http://findarticles.com/p/articles/mi_m0FSL/
is_2_80/ai_n6159709.

FIGURE 26–7 䊏 Correct surgical attire.
proper OR attire and a surgical team member in scrub apparel,
highlighting important standards and principles.
Positioning the Patient to Prevent Injury
Patient positioning in the OR is chosen to accommodate surgi-
cal access, staff ergonomics, and surgical view while maintaining
the patient’s skin integrity. It is for this reason that OR tables are
narrow (ergonomic for surgeon) and firm (limits movement
and allows for CPR). OR tables and accessories are designed to
accommodate a wide range of positions in order to allow for the
use of gravity to displace organs in order to provide additional
working space, surgical access, enhanced ergonomics for profes-
sionals, and prevent patient complications.
Complications secondary to positioning include compro-
mised respiratory or circulatory responses, injury to nerves and
muscles, and the development of pressure ulcers. Chart 26–4 lists
common intraoperative positioning complications and potential
causes. Nurses may review patient’s intraoperative position via
the OR record and assess any relevant patient outcomes. Of these,
pressure ulcers have received much attention as a preventable in-
traoperative complication. The incidence of pressure ulcers in
CHART 26–4 Intraoperative Positioning Complications
Potential Complications Secondary to Intraoperative Positioning
Decreased lung expansion due to supine position resulting in
compromised respiratory effects
Brachial plexus nerve injury
Circulatory obstruction due to position resulting in increased risk of
postoperative deep vein thrombosis
Integumentary injury resulting in pressure ulcers, abrasion, and
blistering
Dislocation of acetabulum
CHAPTER 26 Intraoperative Nursing 637
surgical patients ranges from 4% to a high of 45% depending on
the study (Feuchtinger, Halfens, & Dassen, 2005; Price, Whitney,
& King, 2005). Researchers report conflicting data on risk factors
for the development of pressure ulcers. However, preoperative
risk factors commonly cited across studies include age (e.g., older
patients); presence of comorbidities particularly diabetes, hyper-
tension, and vascular disorders; and poor nutritional status as
measured by low serum albumin and anemia (Feuchtinger et al.,
2005; Price et al., 2005). Further research is needed to clarify in-
traoperative risk factors but those that are suggested include type
of surgery (e.g., higher risk with vascular, cardiac, thoracic, and
spinal surgery), length of operation (e.g., longer surgeries), care
taken during perioperative skin preparation to reduce unneces-
sary moisture collection under the skin, hypotensive episodes
during surgery reducing the blood available to tissues, and the
type of anesthetic used. Perioperative nurses need adequate
knowledge of anatomy and an understanding of the physiological
effects of specific surgical positions. Appropriate positioning ac-
cessories and excellent communication between the anesthesia
team monitoring physiological responses and the surgical team
often requesting position changes is essential in order to prevent
patient injury.
The primary objective of patient positioning for surgery is to
provide maximize exposure while ensuring patient safety.
For example, proper positioning can help maintain proper
body alignment and access to intravenous and anesthesia
support devices.
Preventing the Retention of Foreign Objects
Surgical counts are the responsibility of perioperative nurses and
are performed in order to prevent patient injury due to the high
risk of retained foreign body, which can include gauzes, needles,
or instruments. Retained foreign objects in patients have resulted
in major injuries such as sepsis, bowel perforation, and death.
Most facilities follow a legal counting procedure based on the
AORN (2007b) recommended standards and practices. The de-
sired patient outcome is a patient free from injury related to ex-
traneous objects. It seems to be a much greater issue than
reported, leading to an initiative by health care professional or-
ganizations, such as AORN, American College of Surgeons (ACS),
Potential Intervention
Position bolsters correctly to minimize compression of thorax, facilitating full
lung expansion.
Position arm correctly to ensure proper arm alignment of less than 90 degrees,
supinated, and adequately padded and protected.
Apply antiembolic stockings and sequential compression leggings. Use
appropriate prophylactic anticoagulant medication administration.
Use OR table equipment that will minimize pressure and maximize capillary
refill. Appropriate equipment includes gel mattresses. Ensure proper lifting and
securing of patient to prevent friction-related injuries.
Ensure proper placement of stirrups and ensure that two health care
professionals simultaneously lift, support, and place legs onto stirrups
observing correct alignment.
 638 UNIT 5 Nursing Management of the Surgical Patient
and the Joint Commission, to develop improved methods of ac-
counting for surgical items. One technology that is currently be-
ing tested is radio-frequency identification (RFID). This involves
RF tags being implanted in surgical sponges (Figure 26–8 䊏). This
permits the surgical team to pass a wand over the patient follow-
ing a procedure to verify that no sponges have been left in the pa-
tient (Medline, 2006).
The presence of foreign materials in the body can lead to in-
fection, abscess, and other serious problems. Multiple proce-
dures are in place to prevent leaving an instrument or a sponge
or other material in the patient when the wound is closed.
Sponges, swabs, instruments, and sharps are counted many
times during the surgical procedure. Hospitals have written
policies describing what is counted, when it is counted, who
does the counting, where the counting is documented, and how
to resolve a discrepancy in the count. To prevent a foreign object
from being left behind:
• All items brought to the operating room are documented.
• No items are removed from the operating room until the fi-
nal count is complete and verified.
• Sponges, swabs, and other items are counted before surgery,
before wound closure begins, and before skin closure begins.
• The circulating nurse and scrub nurse count items in unison.
• The circulating nurse and scrub nurse document the count in
the record.
If there is a discrepancy in the count, all personnel try to locate
the missing item. If it cannot be found, the patient may be x-rayed.
Surgical instruments can be seen by x-ray and soft materials,
such as surgical sponges, have a radio-opaque stripe for x-ray
identification.
Estimating Blood Loss
The patient is monitored throughout the operation for blood loss.
The calculation of blood loss is referred to as the estimation of
blood loss (EBL). Blood in suction containers, wound drains,
chest tubes, and nasogastric tubes is measured directly at frequent
intervals during the surgery. If irrigating fluid is used, it is sub-
tracted from the total amount of drainage to determine the
amount of actual blood loss. Blood in sponges can be approxi-
(a) (b)
FIGURE 26–8 䊏 RFID technology: (A) RF tag implanted in surgical gauze; (B) wand to detect the RF tag in surgical gauze; (C) surgical RFID detection
console.
mated from their weight with 1 gram of weight being equal to
1 mL of blood. Blood-soaked sponges are collected in a plastic bag
and weighed. The weight of the dry sponge(s) and plastic con-
tainer is subtracted from the total weight to determine blood loss.
Whether or not the patient needs a transfusion during sur-
gery depends on blood loss as well as on other factors such as
age, general level of health prior to surgery, history of cardiovas-
cular disease, how well the patient tolerates the blood loss, and
the availability of autologous blood. Some religions, such as
Christian Science and Jehovah’s Witnesses, restrict the adminis-
tration of blood products.
Adult patients who are generally healthy can tolerate surgical
blood loss of up to 500 mL without the need for a transfusion.
Blood loss is treated with the administration of packed red blood
cells. Chapter 23 provides a complete description of blood
8
administration indications and procedures.
Latex Allergy
There has been a significant increase in the number of latex aller-
gies seen in the hospital, including the operating room. Some sug-
gest the increase correlates with the adoption of universal
precautions and the increased use of latex gloves. Patients are
asked preoperatively about the possibility of latex allergy. A latex
sensitivity questionnaire can be used to identify those who have a
latex allergy or who are likely to develop the allergy. A high inci-
dence of latex allergy is found in people with spina bifida, patients
who have had multiple surgeries, those who work with latex prod-
ucts (health care workers, dental industry workers, rubber work-
ers), and those with a genetic predisposition to allergies (atopy).
Patients who report allergies to kiwis, bananas, and avocados are
also at an increased risk of latex allergies due to the cross reactiv-
ity of the proteins present in these fruits and latex. Blood or skin
tests can detect latex-specific IgE antibodies and are performed
preoperatively when latex allergy is suspected. Latex allergy is dis-
cussed in detail in Chapter 60 .
8
It is virtually impossible to create a latex-free environment in
the operating room—although it may be possible in the future
as more products are being manufactured without latex. For pa-
tients with known allergy, a latex-reduced environment is cre-
ated. Elements of a latex-reduced environment in the operating
room include (1) scheduling elective cases as the first cases of the
(c)
 CHAPTER 26 Intraoperative Nursing 639

day to minimize contact with aerosolized allergen from latex
gloves, (2) using vinyl gloves rather than latex gloves, (3) using
powder-free gloves to limit the aerosolization of latex antigens,
(4) avoiding latex on the sterile field, (5) using a plastic anesthe-
sia mask, (6) using a stopcock rather than the rubber port for in-
jection of intravenous drugs, (7) removing the rubber cap on
medication vials rather than drawing a medication through the
cap, (8) using nonlatex equipment such as blood pressure cuff,
stethoscope, and electrocardiogram leads, and (9) using nonla-
tex tape. Premedication of allergic patients with steroids or an-
tihistamines is not recommended.
Allergic responses to latex can range from mild cases of con-
tact dermatitis evidenced by a rash and urticaria to serious cases
of anaphylaxis. When a latex allergy is suspected in the operat-
ing room, the source of latex in direct contact with the patient is
immediately removed. Follow-up treatment includes the ad-
ministration of 100% oxygen, intravenous fluids to support the
blood pressure, and the administration of intravenous epineph-
rine. Diphenhydramine and steroids may also be given intra-
venously to attenuate the allergic response.
Postanesthesia Care Unit
Once the surgery is completed, the anesthetist and the nurse will
accompany the patient to the postanesthesia care unit (PACU)
for further monitoring. Concerns along this route will focus on
safety, infection control, medication, communication, position-
ing, and equipment. The PACU is where the patient will recover
from the anaesthetic he has received. This is an unrestricted area
where the patient will no longer need to wear a head cover and
the nurses will wear regular uniforms. Visitors may be allowed
in certain parts of the PACU under certain circumstances.
Poor communication is one of the top contributing factors
to medical errors. Therefore, nurses must strive to provide ef-
fective and consistent information during patient handoff to a
transition unit such as the PACU or Intensive Care Unit (ICU).
It is important to give any pertinent information to the unit
members where the transfer of responsibility for the surgical
patient is occurring and provide an interactive communication
that is free of interruptions and includes a systematic process
of verification. Figure 26–9 䊏 (p. 640) shows a mnemonic that
highlights the handoff principles and verification process.
PACU is dicussed in detail in Chapter 27 . vironment (Prough, 2005).
8
Gerontological Considerations
Persons 65 years of age and older, require surgical interventions
more often than younger persons because of age-related system
changes and comorbid conditions. Degeneration of multiple
systems such as the musculoskeletal, nervous, cardiovascular,
respiratory, genitourinary, endocrine, and hematopoietic sys-
tems and hearing and vision can influence intraoperative and
postoperative outcomes. Changes in pharmacokinetics result
in changes in drug absorption, distribution, metabolism, and
excretion by the body. At this stage of life, both physical and
cognitive abilities may vary greatly. Appropriate age-specific
interventions should be considered for the geriatric popula-
tion taking into consideration both physical, cognitive, senso-
rimotor, and psychosocial factors. The Gerontological
Considerations box highlights the special considerations for
the gerontological population.
Assess the geriatric patient’s history and general health status,
in particular medications, previous surgeries, and comorbidi-
ties. Promote patient warmth through warming devices and as-
sess range of motion prior to patient being anesthetized in order
to ensure correct positioning accessories are available. Addi-
tional padding may be necessary due to decreased adipose tissue
and circulation, predisposing the patient to the development of
pressure ulcers. Efforts should be made to diminish the use of
tapes that may lead to denuding of geriatric fragile thinner skin.
Ensure adequate time is available to communicate clearly and
slowly, keeping in mind possible hearing impairment and need
for additional processing and response time.
Hyperglycemia is known to be associated with increased sep-
sis, suggesting that careful monitoring of glucose levels may be
a way to reduce serious postoperative infections. Infections are
a major concern for all hospitalized patients, but are especially
dangerous for elderly persons. General risk factors for infection
in elderly patients are known to include frailty, chronic under-
nutrition, reduced muscle mass, and poor dentition. Other
more general factors common to all age groups are diabetes, as-
piration, and the presence of an indwelling urinary catheter.
Patients with postoperative cognitive dysfunction (POCD)
experience deterioration in cognitive function that persists for
years after the operation. POCD may be related to brain oxy-
genation during anesthesia, anesthetic agents, and hospital en-

GERONTOLOGICAL CONSIDERATIONS for Elderly Patients Having Surgery

Physical Factors
• Decreased tolerance to heat
and cold
• Loss of skin tone
• Declining cardiac/renal
function
• Atrophy of reproductive
organs
• Increased incidence of
preexisting health
conditions
Cognitive Factors
• Decline dependent on pregeri-
atric state and general health
and social involvement
• Decreased memory, inductive
reasoning, and figural relations
may occur
• Cognitive tasks may require
more time to complete
Sensorimotor Factors
• Decreased visual acuity
• Diminished hearing
• Altered tactile sensation
• Changes in taste and smell
• Diminished response to
stress and sensory stimuli
• Decreased mobility
Psychosocial Factors
• Ego integrity important
• Stressors: end of life, changes in
environment, increased cognitive
demands
• Death of loved ones
• Concerns for general health
increase
 640 UNIT 5 Nursing Management of the Surgical Patient

“I PASS THE BATON”

Handoffs and Healthcare Transitions
with opportunities to ask
QUESTIONS, CLARIFY AND CONFIRM

I Introduction Introduce yourself and your role/job (include patient)

P Patient Name, identifiers, age, sex, location

Presenting chief complaint, vital signs and symptoms

A Assessment
S Situation
S SAFETY Concerns
and diagnosis
Current status, medications, circumstances, including code
status, level of (un)certainty, recent changes, response to
treatment
Critical lab values/reports, socio-economic factors,
alllergies, alerts (falls, isolation, etc.)

THE

Co-morbidities, previous episodes, past/home medications,

B Background
family history

What actions were taken or are required AND provide brief

A Actions
rationale

T Timing Level of urgency and explicit timing, prioritization of actions

Who is responsible (nurse/doctor/team)

O Ownership
including patient/family responsibilities

What will happen next? Anticipated changes? What is the

N Next
PLAN? Contingency plans?

FIGURE 26–9 䊏 Handoff protocol to improve communication when transferring a patient from the OR to another unit.
Source: Joint Commission (2008). National Patient and Safety Goals. Retrieved July 3, 2008 from http://www.jointcommission.org/NR/rdonlyres/ACA4DBF6-90FD-4400-BE7E-4C6F881E5DCD/0/
08_OBS_NPSG_Master.pdf.

Prevention of Infection
Clinical Problem
Mild perioperative hypothermia, which is common during major
surgery, may promote surgical-wound infection by triggering
thermoregulatory vasoconstriction, which decreases subcutaneous
oxygen tension. Reduced levels of oxygen in tissue impair oxidative
killing by neutrophils and decrease the strength of the healing wound
by reducing the deposition of collagen. Hypothermia also directly
impairs immune function.
Research Findings
Research was done testing the hypothesis that hypothermia both
increases susceptibility to surgical-wound infection and lengthens
hospitalization. Good et al. (2006) report that hypothermia itself may
delay healing and predispose patients to wound infections.
Maintaining normothermia intraoperatively is likely to decrease the
incidence of infectious complications in patients undergoing colorectal
resection and to shorten their hospitalizations.
Other research was done on prewarming of patients’ skin and its
influence on core hypothermia (Cooper, 2006; Vanni et al., 2003).
Camus et al. (1995) found that a single hour of preoperative skin
surface warming reduced the rate at which core hypothermia
developed during the first hour of anesthesia.
Antibiotic Administration
Another measure to reduce infection in the operating room is proper
timing for antibiotic administration. Antibiotic prophylaxis is being
used in a variety of surgical procedures to reduce the incidence of
surgical-site infections. Antibiotics should be chosen on the basis of
their effectiveness against the pathogens most likely to be
encountered. Skin floras (e.g., Staphylococcus organisms) are the
usual target, so first-generation cephalosporins are most often
chosen. Preoperative prophylactic antibiotics should be administered
within 60 minutes before the initial incision is made to ensure that
antimicrobial levels in the tissue are adequate and maintained for the
duration of the procedure (Gordon, 2006; White & Schneider, 2007). To
comply with the recommendations of administration within 60
minutes of incision, the holding area was identified as the preferred
location (Olin, 2006).
Implications for Nursing Practice
The latest research results have and will influence a change of practice
in the perioperative setting based on evidence. In the preoperative
NCLEX® REVIEW
1. A preoperative patient is taken into the holding area. The
nurse will utilize this time with the patient to do which of
the following?
1. Ensure surgical instruments are operational.
2. Clean and inspect surgical instruments.
3. Conduct an interview.
4. Insert an indwelling urinary catheter if necessary.
CHAPTER 26 Intraoperative Nursing 641
setting nurses can use blankets and warming to maintain
normothermia. For maintaining normothermia in the OR policies and
procedures could be implemented such as use of warming devices
under the patient as well as the use of warm solutions. In addition the
temperature of the OR suite could be increased.
Nurses also can coordinate the timing of preoperative antibiotic
administration. This will necessitate cooperation with both the
surgeon and the OR staff to determine the optimal timing of antibiotic
administration.
Critical Thinking Questions
1. What nursing interventions will decrease the risk of infection?
Answer:
a. Communication with surgical team for timing of antibiotic
administration.
b. Institute measures to maintain normothermia throughout
surgery & PACU.
c. Develop policies that ensure standards are used by all
members of the surgical team regarding warning
procedures.
Answers to Critical Thinking Questions appear in Appendix F.
References
Camus, Y., Delva, E., Sessler, D., & Lienhart, A. (1995). Pre-induction skin
surface warming minimizes intraoperative core hypothermia.
Journal of Clinical Anesthesia, 7, 384–388.
Cooper, S. (2006). The effect of preoperative warming on patient’s postop-
erative temperatures. AORN Journal, 83(5) 1074–1076, 1079–1084.
Good, K. K., Verble, J. A., & Norwood, B. R. (2006). Postoperative
hypothermia—The chilling consequences. AORN Journal, 83(5),
1055–1066.
Gordon, S. M. (2006). Antibiotic prophylaxis against postoperative wound
infections. Cleveland Clinic Journal of Medicine, 73, S42–S45.
Olin, J. (2006). Multidisciplinary approach to optimizing antibiotic pro-
phylaxis of surgical site infections. American Journal of Health-
System Pharmacy, 63, 2312–2314.
Vanni, S. M., Braz, J. R., Modolo, N. S., Amorim, R. B., & Rodrigues, G. R.
(2003). Preoperative combined with intraoperative skin surface
warming avoids hypothermia caused by general anesthesia and sur-
gery. Journal of Clinical Anesthesia, 15(2), 119–125.
White, A., & Schneider, T. (2007). Improving compliance with prophylactic
antibiotic administration guidelines. AORN Journal, 85(1), 173–180.
2. A registered nurse first assistant is scheduled to assist a
surgeon with a surgical procedure. This nurse will be
responsible for:
1. Administering anesthetic agents.
2. Serving as the patient advocate.
3. Providing the surgeon with instruments.
4. Collaborating with the surgeon and suturing the wound
closed.
 642 UNIT 5 Nursing Management of the Surgical Patient

3. During the course of a surgical procedure, the patient’s heart 6. During a surgical procedure the patient begins to
rate increases and the blood pressure drops. The care demonstrate signs of malignant hyperthermia. Which of the
provider who would address these physiological changes to following should be done to support this patient?
the patient would be the: 1. Administer calcium channel blockers.
1. Surgeon. 2. Stop the surgery or deep the anesthesia.
2. Anesthesiologist. 3. Transfer to the PACU for postsurgical care.
3. RNFA. 4. Provide 21% oxygen.
4. Scrub nurse. 7. During a surgical procedure the anesthesiologist directs
4. While conducting a surgical time-out, the nurse says that the another care provider to change the oxygen mix being
site of surgery is the right knee whereas the left knee was provided to the patient. The care provider most likely to
marked as the site of the surgery. Which of the following make this oxygen change would be the:
should be done? 1. RN First Assistant.
1. Operate on the right knee. 2. Scrub nurse.
2. Operate on the left knee. 3. CRNA.
3. Ask a family member which knee is the site of surgery. 4. Respiratory therapist.
4. Stop all preparations until it can be verified which knee is the
site of surgery. Answers for review questions appear in Appendix 5

5. While an anesthetized patient is being moved to the

operating room table, the patient’s lower left leg drops and
hits the side of the table. Which of the following should the
nurse do?
1. Move the leg and place it on the table.
2. Examine the leg for possible or extent of injury and
document the event.
3. Nothing because this is considered an acceptable hazard of
surgery.
4. Elevate the leg on a pillow.

KEY TERMS
Bier block p.631 general anesthesia p.629 peripheral nerve block p.631
circulating nurse p.620 intraoperative p.620 regional anesthesia p.630
conscious sedation p.625 intrathecal anesthesia p.630 scrub nurse p.620
epidural anesthesia p.630 malignant hyperthermia (MH) p.629 spinal anesthesia p.630

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CHAPTER 26 Intraoperative Nursing 643
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