Hey everyone, Professor Marshall again and welcome to part four of our perioperative nursing content. In this section we are going to focus on intraoperative nursing care, so what happens during the time that the patient is in surgery. And primarily we're going to focus on the nurse's role during this time. So I just have a couple pictures here for you of what a typical operating room might look like. The picture on the left obviously is not during a surgery, where the picture on the right shows the operating room when they are in the middle of a case.
Now, as a student, where would you stand to watch the surgery if you had the opportunity to go to clinical and do so? Well, it really depends on the staff and the OR, but primarily they're going to put you outside of the sterile field. which is going to be like start at the patient and kind of work out from there. So you're going to be more on the periphery.
If you're with a good team, then oftentimes they'll work hard to get you somewhere that you can still kind of see what's going on. So maybe up by the patient's head, up near anesthesia, but again, making sure that you stay well out of the sterile field so that you don't contaminate anything. To review, there are kind of two distinct teams in the operating room.
You have your sterile team and you have your clean team. As far as the members who make up the sterile team, that's going to be your surgeon, the surgical assistant who might be another surgeon, it might be a PA, it might be an RNFA, registered nurse first assistant. Your scrub person is part of that sterile team as well. Okay, now what do they do? Well, in terms of preparing for surgery.
These are the folks who are going to scrub in and don sterile gowns, sterile gloves, all of that. They're going to be responsible for handling sterile instruments during the surgery. So where will you find them during the case?
Well, they're going to be within and immediately around the sterile field. Then you have your clean team, and that's going to be your anesthesia care provider, your RN circulating nurse, and any others. Like if...
biomed or radiology tech or anyone like that needs to be in there. You as a student, if you were in there, you'd be part of the clean team. So what do they do? Well, they abide by clean technique.
They're not scrubbed in. So you're going to find them outside of the sterile field, never within it. But instead, they're going to function around it and beyond it.
So I have here in red your sterile team. They... make sure that they are using surgical asepsis and sterile technique, whereas your clean team, they're going to use medical asepsis and clean technique.
And this is just a visual kind of explaining the two a little bit more. Medical asepsis there on the left and surgical asepsis on the right. So clean team versus sterile team. So I briefly covered the nurse's role in the operating room in the audio prep, but I just want to get into some more specifics of the role. So you can see I've kind of put some key terms on the top of the slide here.
Advocacy, safety, dignity, confidentiality, privacy. It's going to be the circulating nurse in the operating room who really does all of these things for the patient. Remember, the patient undergoing surgery typically...
If we're talking general anesthesia, they can't speak during the procedure. They're not awake. They cannot do anything in terms of advocating for themselves or speaking for themselves.
So it's going to fall on the nurse to do that. And again, because the patient is asleep, it's going to be the responsibility of the circulating nurse to make sure that their privacy is maintained, that only areas that need to be exposed are exposed. We want to maintain the patient's dignity even though they're not awake and wouldn't know otherwise.
Now, before the patient even comes back for the surgery into the operating room, the circulating nurse is going to prepare the room with the team before transferring the patient. So he or she is going to ensure that all the necessary supplies are available. Usually there's some kind of surgeon preference card that says for this type of surgery with this type of patient here are the instruments and all of the different things that they want in the room so the circulating nurse remains in the not sterile field while the scrub sets up the sterile items and then the circulator will go and get any additional items that they might need. The nurse in the operating room will also make sure that all of the electrical and mechanical equipment gets checked for proper function because obviously safety is a huge priority in this particular setting and there are a lot of things in there that could be very dangerous.
So they're going to make sure that all of that stuff is working properly. And then they ensure that aseptic technique is practiced. when instruments and supplies are being placed on the sterile field.
So it's the scrub person who's placing it, but the RN might be opening packaging, but he or she will definitely be watching to make sure that sterility is maintained by that scrub person. And if sterility is broken, the circulator is going to say, hey, heads up, you just broke sterility. Let's get new stuff.
We need to start over here. Part of this includes a sponge, sharps, and instrument count. So both the circulator and the scrub are going to count all material that is added to the sterile field, every single sponge, every single instrument. And then, so they do that as they're setting up the room before the case starts, but then as the surgery is ending, right before the surgeon closes, they're gonna repeat that count to make sure that nothing gets left in the patient. So.
All of that stuff needs to be accounted for again because you want to make sure that something like this doesn't happen. Now these are thankfully pretty uncommon. Probably the most common thing that gets left in a patient during surgery would be like a surgical sponge, some gauze, that kind of thing. But that being left in a patient can lead to...
Serious infection for the patient can lead to obviously the need for additional surgeries to have it removed and all of that. So the counts are really important. Now, right before the surgery, the RN circulator is going to complete a chart review.
They'll note any abnormalities or any changes. They'll do a quick reassessment of the patient. Then they'll ask a few last-minute questions about valuables, any prostheses, contact lenses.
when the patient last had food, fluids, etc. They'll also answer any last-minute questions that the patient might have and then they're going to verify that those skip measures have been done. If there are any prophylactic antibiotics, those need to be started within 30 to 60 minutes before the incision.
Maybe they'll be applying a warming blanket or some SCDs as part of those skip measures. Then As you can see in the picture here, most hospitals require that the patient wear a hair covering and then they're going to be transferred into the operating room. And it will be the operating nurse, the circulator, who takes the patient into the operating room after they've done any necessary prep in the pre-op area. Now usually they're going to take them in via stretcher but Once in a while they'll walk in, but usually they're wheeled in.
Now, if they've had any pre-op sedation, they obviously wouldn't be able to walk in on their own because of safety. Then another big part of the operating room nurse's role is patient positioning. So this is a really critical part of every procedure, and the positioning usually happens following the administration of anesthesia. So the patient's not going to feel.
pain impulses so if you put them in an awkward uncomfortable position they're not going to be able to tell you that so you have to be really careful about getting the patient positioned properly obviously again the focus will be on safety and on preventing any injury so we need correct skeletal alignment we want to prevent any pressure on nerves any excess pressure on the skin bony prominences around the eyes we want to make sure we're not occluding any arteries or veins. Here are some ways that patients are commonly positioned in the operating room. Supine, prone, lateral, lithotomy, all very common depending on the type of surgery. Now, obviously one of the factors that we need to take into consideration is the surgeon's ability to reach the area that's being operated on. But even more important than that is going to be the anesthesia provider's ability to access and maintain the patient's airway during the surgery.
So supine position is by far our most common. surgical position, but again depends on what surgery is being done, but it's good for abdominal surgeries, heart surgeries, chest, breast surgeries, things like that. The prone position you can see here on the right is often a good choice for many back surgeries because it allows easy access, but you can see that the table is positioned in a way that the patient's airway would still be accessible. by anesthesia because anesthesia is always going to be up there at the head of the bed. And I did post a supplemental handout for you on Canvas that shows these positions again, but what's nice about that handout is that it lists some of the risks with each of these positions and also some safety considerations for the nurse.
The OR nurse is also going to be the one that prepares the surgical site. Remember skin preparation is going to just help reduce the number of microorganisms that are available to potentially migrate into that surgical wound. So our RN circulator is going to scrub or clean around the surgical site with antimicrobial agents in a circular motion from clean to dirty.
Then they're going to allow that to dry completely because those antiseptic agents that are used for skin prep often contain alcohol and they can be flammable so that's a big risk in the OR setting. Hair might be removed with clippers, but again we don't typically do shaving anymore. And then after the patient is prepped, then the sterile team members will move in and drape the area so that only the incision site is left exposed.
And then the last big part of the OR nurse's role is assisting the anesthesia care provider. So... Because of this, the RN circulator needs to understand the mechanism of action, the pharmacologic effects of the different anesthetics that are being used in the OR setting. They need to know the location of emergency equipment and emergency drugs in the OR.
They're going to be the ones placing monitoring devices on the patient, so blood pressure cuff, pulse ox, something to monitor temperature, ECG. leads, all of that stuff. And then what else? They're going to serve as the communication link between anesthesia and the other departments like the lab or the blood bank. So anesthesia might decide that the patient needs some more blood, that they've lost a lot of blood and they want to transfuse them.
So then it would be the circulating nurse who would contact the blood bank to get the blood sent into the OR suite. And then it's going to be the OR nurse and the anesthesia care provider together who typically take the patient from the OR after surgery to the PACU. They'll give report then to the nurse in the PACU for that nurse to assume care.
I next want to mention some gerontologic considerations for our patients, our elderly patients undergoing surgery. So first of all, we have to keep in mind that their anesthetic drugs need to be carefully titrated because of the physiologic changes that we see as part of the aging process that can alter how the patient responds to anesthesia. We want to make sure that we assess them for poor communication.
If they have any sensory deficits, that can decrease their ability to communicate and follow directions. Our older patients are going to be at an increased risk from tape. electrodes, warming blankets, cooling devices, things like that because they you know they've lost skin elasticity as part of the aging process so they're going to be more prone to skin tears so we need to be careful. These patients may also have osteoporosis and or osteoarthritis so we need to be careful when we're positioning them so that we don't cause any long-term injury or disability.
And then perioperative hypothermia. This is a risk for any surgical patient, but especially for our geriatric surgical patients. Our older adults are at greater risk of developing perioperative hypothermia, so it's going to be really important that we closely monitor their temperature during surgery.
The last thing I want to talk to you about here is the universal protocol, which you might recall is one of the national patient safety goals. that's intended to prevent mistakes in surgery. So to prevent the wrong procedure, the wrong site, the wrong patient type incidents in the operating room. So a big part of this is the surgical timeout.
and it's done just before the procedure starts. Now I posted a video showing this for you on canvas so make sure that you take a look at that but basically what happens is that all the team members stop what they're doing. Someone calls okay let's do the timeout everybody stops what they're doing and they do a final verification process to make sure that they have the right patient. So they wait have the patient state their name, their date of birth.
When they come into the operating room, they're going to check their wristband, check that MR number, make sure they have the right patient. Okay. Then they want to do the right surgery. So they're going to ask the patient to state what surgery they're having done. They're going to verify that with the surgeon.
They're going to take a look at the consent, make sure that the consent matches what the patient's saying, what the surgeon is saying. And then they want to make sure that they do this on the right site. So they'll...
confirm what part of the body, check and make sure it's been marked and that everything kind of jives. Now I also, in addition to that video, I did post some handouts about the universal protocol and about the surgical time out and you can find those on Canvas as well. One of those handouts is the World Health Organization's surgical safety checklist.
You also have a copy of that in your textbook as well, but the use of that has really improved. compliance with surgical standards and has really helped to decrease complications from surgery. Okay, so that's it for intraop short and sweet because it is a specialty area and if you decide that's where you want to work then they're going to give you a lot of additional training in that area focusing on sterility and things like that.
My husband was an operating room nurse for I don't know, maybe 16, 17 years. And when he first transferred into the operating room, they sent him to Gateway. Gateway has an OR program, so his employer sent him to Gateway and paid for him to take a semester-long operating room nursing course.
All right, that is the end of part four, and I will see you shortly in part five for the first section of post-operative nursing care. Thanks guys.