Learning Objectives
By the end of this section, you will be able to:
- Explain appropriate application of the clinical judgment medical model (CJMM) for a patient during surgery
- Identify appropriate education for the patient during surgery
- Discuss potential complications and corresponding interventions during the surgical experience
Nurses play a pivotal role in ensuring the safety, comfort, and well-being of patients throughout the surgical journey. In the dynamic and intricate environment of the operating room, intraoperative nurses serve as crucial members of the surgical team, with responsibilities that range from patient advocacy and communication to aseptic technique and surgical site care. As advocates for patient safety and guardians of infection prevention protocols, intraoperative nurses contribute significantly to the seamless execution of surgical procedures.
The Clinical Judgment Measurement Model: The Patient During Surgery
The clinical judgment measurement model (CJMM) is a systematic and patient-centered approach aimed at ensuring the delivery of safe and effective care. For a patient who is having surgery, this includes the pre-operative, perioperative, and postoperative periods. The process typically begins with a thorough pre-operative assessment, where the nurse collects comprehensive information about the patient’s health history, medications, allergies, and psychological status. This assessment lays the foundation for individualized care planning, addressing the unique needs and potential risks of the patient. During the intraoperative phase, nurses are actively involved in patient positioning, maintaining a sterile environment, and collaborating with the surgical team to ensure optimal conditions for the procedure. Continuous monitoring of vital signs, administering medications as prescribed, and addressing any emergent issues are crucial components of nursing care.
Nursing Care
In the intraoperative phase, nursing care plays a critical role in ensuring the safety, comfort, and well-being of the patient undergoing surgery. The intraoperative phase encompasses the time from when the patient enters the operating room until their transfer to the post-anesthesia care unit. Nursing care during this phase involves a range of responsibilities that contribute to the overall success of surgical interventions. Pre-operative assessments should encompass a thorough review of the patient’s medical history, including chronic conditions, medications, and any potential age-related impairments. Monitoring vital signs becomes even more crucial in the older adult population, considering the heightened risk of cardiovascular and respiratory complications. Maintaining a normal body temperature is essential, as older adults may be more susceptible to temperature fluctuations. Particular attention should be given to preventing postoperative delirium, a common concern in older adults, through strategies like minimizing anesthesia exposure and ensuring a quiet, familiar environment during recovery. Additionally, collaboration with the patient’s family or caregivers is vital, as they often play a significant role in providing support and ensuring continuity of care during the perioperative period. Communication strategies should be adjusted to accommodate potential sensory deficits or cognitive impairments.
Life-Stage Context
Gerontological Considerations
When caring for older adults in the intraoperative phase, nurses must consider various gerontologic considerations to ensure optimal outcomes. Age-related changes, such as altered pharmacokinetics, need to be considered when caring for older adults. For example, older adults metabolize mediations at a slower rate and dosage should include renal considerations. They may have a more increased effect of medication due to decreased metabolism. Older adults also have a reduced physiological reserve, meaning they often have multiple comorbidities that prevent “bouncing back” from anesthesia as fast as they could when younger and in a healthier state. Older adults tend to have blood pressures in the lower range after administration of anesthesia for longer periods of time than a younger, healthier people. Older adults are also at increased susceptibility to complications, such as airway complications and increased risk of infection, due to lower immunity thresholds, all of which necessitate a tailored approach.
Cultural competence is imperative in intraoperative nursing care to provide patient-centered and respectful treatment. Cultural considerations encompass a range of factors, including beliefs, values, practices, and preferences. Understanding a patient’s cultural background enhances communication, builds trust, and contributes to positive patient outcomes. Language barriers may arise, requiring the use of professional interpreters to ensure accurate communication with the patient and their family. Respect for cultural norms regarding modesty and privacy is crucial when positioning and draping patients in the operating room. Moreover, dietary restrictions, religious practices, and rituals should be considered during pre-operative preparations and postoperative care. Cultural competence extends beyond the patient to the entire surgical team. Sensitivity to diverse cultural perspectives within the team fosters effective collaboration and enhances the overall quality of care.
Cultural Context
Religious and Spiritual Practices in the Operating Room
A cultural consideration in the intraoperative phase revolves around the use of human-derived products. For example, many Jehovah’s Witnesses do not accept any human-derived product, such as blood, for medical treatment, as it is against their beliefs. Because surgical procedures can cause a need for blood transfusions, alternative medical approaches should be considered. Some Jehovah's Witnessess may be willing donate their own blood for use during the procedure, but this may not be an option for all. It is important to note that Jehovah’s Witnesses’ beliefs may vary, but health-care providers should plan for no use of human-derived products for these patient populations during surgery
(Cho et al., 2019)
Postoperatively, nursing care extends to the recovery phase, including monitoring for complications, managing pain, and facilitating the patient’s transition to a stable condition. Effective communication with the patient, their family, and other health-care team members is important for fostering trust and ensuring the delivery of holistic care that aligns with the patient’s unique needs and preferences.
Read the Electronic Health Record
Intraoperative EHR Information Verification
Patient Information
Name: Mrs. Joan Smith
Date of Birth: 03.04.1954
Medical Record Number: 290879999
Procedure: Emergency laparotomy for acute bowel obstruction confirmed by X-ray and CT scan
Allergies: Latex
Pre-operative Assessment:
- Vital Signs: Stable
- PMH: HTN, DM
- Medication: Metformin, lisinopril
- Social History: Lives alone, no one with her
- Surgical History: The appendix was removed when the patient was 7 years old.
- Surgical Consent: Signed and completed appropriately.
- Blood Consent: Declined due to religious beliefs.
- Advance Directives: Not available
Recognizing Cues
The assessment phase of the nursing process during surgery is a foundational step in providing individualized and comprehensive care to the patient. This critical stage involves a thorough and systematic gathering of information about the patient’s health status, medical history, and psychosocial factors. Pre-operative assessments include evaluating the patient’s baseline physiological parameters, identifying potential risks and allergies, and obtaining a detailed medication history. Additionally, the nurse assesses the patient’s emotional and psychological well-being, addressing any concerns or anxieties related to the impending surgical procedure. This holistic approach ensures that the nursing care plan is tailored to the unique needs of the individual. During the intraoperative phase, ongoing assessments involve monitoring vital signs, ensuring proper positioning, and promptly addressing any emergent issues. The assessment continues postoperatively, focusing on the patient’s response to the surgical intervention, pain management, and the detection of potential complications. A comprehensive and diligent assessment is the cornerstone of effective nursing care during surgery, guiding subsequent interventions and contributing to the overall well-being and safety of the patient throughout the perioperative period.
Analyzing Cues and Prioritizing Hypotheses
In the nursing process for the patient during surgery, the diagnosis and identification of collaborative problems are integral steps aimed at formulating a precise and patient-centered care plan. Following the comprehensive assessment, nurses analyze the collected data to identify actual and potential health issues. Diagnosing involves synthesizing information to recognize the patient’s responses to the surgical experience, potential complications, and any pre-existing conditions. Common nursing diagnoses during surgery may include impaired gas exchange, risk for infection, anxiety, and altered comfort. Collaborative problems, which require joint efforts with other health-care team members, are also identified. This collaborative aspect is crucial, involving effective communication and teamwork to address issues that fall beyond the scope of independent nursing interventions. The nurse collaborates with surgeons, anesthesiologists, and other health-care professionals to manage complex situations and ensure a seamless continuum of care. Accurate diagnosis and collaborative problem identification lay the groundwork for an effective nursing care plan, allowing the health-care team to anticipate, prevent, and address potential challenges, thereby promoting positive surgical outcomes and enhancing the overall well-being of the patient.
Generating Solutions
The planning phase of the nursing process for the patient during surgery is a meticulous and patient-centered endeavor that involves formulating a comprehensive care plan tailored to the individual’s needs. Building upon the earlier stages, the nurse collaborates with the health-care team to establish clear and achievable goals and interventions. Planning encompasses a range of considerations, including the type of surgery, the patient’s health status, and any potential complications. Strategies for maintaining aseptic technique, ensuring proper patient positioning, and managing pain are integrated into the plan. Attention is given to preventive measures, such as infection control protocols and risk reduction strategies. In collaboration with the patient, the nurse discusses the plan, sets expectations, and addresses any concerns. Flexibility is key, as the plan may need adjustments based on the evolving dynamics of the surgical process. Through effective planning, nurses strive to optimize patient outcomes, enhance recovery, and contribute to a positive and safe surgical experience for the patient.
Taking Action
The intervention phase of the nursing process during surgery involves the execution of a carefully devised care plan to ensure the safety, comfort, and well-being of the patient. Intraoperatively, nurses play a vital role in implementing aseptic techniques to maintain a sterile environment, assisting with patient positioning to optimize surgical access, and monitoring vital signs to address any deviations from normal parameters promptly. Medication administration, including anesthesia and other prescribed drugs, is carried out with precision. The nurse collaborates closely with the surgical team, providing essential information, anticipating needs, and addressing any emergent issues. Pain management interventions are initiated to ensure the patient’s comfort postoperatively. Moreover, the nurse acts as an advocate, consistently communicating with the patient, their family, and other health-care team members to uphold the highest standards of care and keep all parties informed and reassured throughout the surgical process. The implementation of these interventions demands a blend of clinical expertise, compassion, and effective communication, reflecting the commitment of nurses to optimizing patient outcomes during the intricate phases of surgery.
Evaluating Outcomes
The evaluation phase of the nursing process for the patient during surgery is a critical step in assessing the effectiveness of the care plan and interventions. Nurses systematically review the patient’s response to the surgical experience, monitoring for expected outcomes and identifying any unanticipated complications. Parameters such as vital signs, pain levels, and the patient’s overall well-being are continually assessed to gauge the success of the implemented interventions. The nurse collaborates with the health-care team, including surgeons and anesthesia providers, to ensure a holistic perspective on the patient’s condition. Any deviations from the expected outcomes prompt a reassessment of the care plan, allowing for necessary adjustments to enhance patient recovery and address any unforeseen challenges. Continuous communication with the patient is maintained to gather feedback and address concerns. Successful evaluation of the nursing process not only contributes to positive patient outcomes but also provides valuable insights for refining perioperative care practices and promoting continuous improvement within the surgical setting.
Unfolding Case Study
Care of the Surgical Patient: Part 2
See Care of the Surgical Patient: Part 1 for previous information on this patient.
| Nursing Notes | 3/12/24, 9:30 a.m. Assessment Patient is escorted to the OR suite with the surgical nurse. The patient is planned for general anesthesia. Education provided by intraoperative nurse regarding time frame a typical partial knee replacement operation typically lasts. |
| Flow Chart | Intraoperative Patient Education The nurse reinforced teachings from the surgeon, asking the patient if they have any follow-up questions. The nurse explains, we will start with inspection of the left knee joint. The surgeon will make an incision at the front of the knee. They will then explore the three compartments of the knee to verify that the cartilage damage is, in fact, limited to one compartment and that the ligaments are intact. If the surgeon feels that the knee is unsuitable for a partial knee replacement, they may instead perform a total knee replacement. The surgeon will have discussed this contingency plan with the patient before the operation to make sure they agree with this strategy. The intraoperative nurse explains a partial knee replacement operation typically lasts between 1 and 2 hours and explains the equipment and monitoring devices in the surgical suite and general anesthesia administration by the anesthesiologist. 3/12/24, 9:00 a.m. Pre-intubation Blood pressure: 126/80 mm Hg Heart rate: 96 bpm Respiratory rate: 20 breaths per min Temperature: 98.1°F / 36.7°C Oxygen saturation: 98% on room air Physical examination: Head, eyes, ears, nose, and throat (HEENT): pupils equal and reactive to light, mucus membranes dry, no thyroid enlargement Lymphatic: lymphatic nodes were not swollen or enlarged Respiratory: respirations easy and unlabored, without dyspnea or shortness of breath, lungs clear with auscultation Cardiovascular: cardiac monitor displays normal sinus rhythm (NSR) with a rate of 96 bpm Abdomen: soft, denies pain, abdomen not distended, bowel sounds present all four quadrants Musculoskeletal: No weakness or numbness in all four extremities, moves all extremities with limited mobility of her left knee Skin: Warm and dry |
| Flow Chart | 3/12/24 10:00–13:00 Intraoperative phase: As the surgery begins, Mrs. Johnson was induced with general anesthesia, with the surgical team administering the medications. The anesthesiologist also administers antiemetics during the intraoperative phase to prevent her from hyperemesis postoperatively. The patient has several risk factors for hyperemesis postoperatively. These include female sex, history of prior reaction to anesthesia medications immediately postoperative, motion sickness, and a nonsmoker. The patient experienced very minimal estimated blood loss (EBL). Patient tolerated the procedure well. Patient had intermittent hypotensive readings with blood pressure ranging from 88/58 mm Hg, 90/60 mm Hg, 87/48 mm Hg during the surgery and received two 1,000 ml IV fluid over 3 hours. O2 saturation remained 97–100%. Heart rate was 88 bpm to 112 bpm and sinus rhythm was borderline sinus tachycardia. Hypotension can be the result of significant blood loss, fluid shift, third spacing losses, lack of oral intake or changes in vascular permeability as a result of the anesthesia. Assessment Post-Intubation Blood pressure: 120/76 mm Hg Heart rate: 88 bpm Respiratory rate: 20 breaths per min Temperature: 96.0°F / 35.5°C Oxygen saturation: 100% |
| Diagnostic Tests/Imaging Results | Intraoperative pre-discharge to post-anesthesia unit (PACU) Intraoperative diagnosis: L knee x-ray of total left knee replacement. The postoperative radiographic impression confirmed the left total knee replacement prostheses and their specific indications along with a detailed review of the patient post-surgical anatomic and critical angles, alignment, and correct positioning of femoral and tibial components was successful. |
Patient Education
Patient education is a pivotal component of nursing care during surgery, aiming to empower individuals with the knowledge and understanding necessary to participate actively in their care and recovery. Pre-operative education involves providing information about the surgical procedure, potential risks, and expected outcomes. This helps alleviate anxiety and fosters a sense of preparedness. Clear instructions regarding pre-operative fasting, medication management, and postoperative expectations contribute to a smoother perioperative experience. Intraoperatively, nurses educate patients about the monitoring devices, anesthesia administration, and any specific aspects of the procedure. Postoperatively, comprehensive education covers topics such as pain management, wound care, and activity restrictions. The nurse tailors information to the individual’s learning preferences, ensuring comprehension and addressing any concerns. A well-informed patient is better equipped to collaborate in their care, make informed decisions, and actively participate in the recovery process. Patient education not only enhances the patient’s experience but also plays a crucial role in promoting positive outcomes and preventing complications throughout the surgical journey.
Potential Complications During the Intraoperative Phase
The goal of any surgical procedure is to achieve optimal outcomes and promote patient well-being. However, the complexity of surgery inherently introduces the potential for intraoperative complications. Any complications can create challenges that require swift identification and management. From unforeseen changes in a patient’s physiological status to technical difficulties within the operating room, understanding and addressing these potential complications are crucial for the surgical team.
Nausea and Vomiting
Nausea and vomiting are recognized as potential intraoperative complications that can significantly impact the well-being of patients undergoing surgical procedures. Referred to as PONV, this complication is multifactorial, influenced by patient-related factors, surgical characteristics, and the type of anesthesia administered. PONV can be distressing for patients, affecting their immediate postoperative recovery experience. Risk factors for PONV include female sex, a history of motion sickness or previous PONV, nonsmoking status, and the use of certain anesthetic agents. Anesthesia providers employ proactive strategies to minimize the risk of PONV, including the administration of antiemetic medications, appropriate fluid management, and the avoidance of volatile anesthetics or opioids when possible. As part of comprehensive perioperative care, anesthesiologists remain attentive to patient risk factors, continually refining strategies to reduce the incidence of PONV and improve the overall surgical experience.
Anaphylaxis
Anaphylaxis is a rare but critical intraoperative complication that demands immediate attention and intervention. It can occur in response to various substances, including medications administered during surgery (e.g., antibiotics, muscle relaxants) or latex-based products used for the procedure. Anaphylaxis manifests rapidly; patients may exhibit difficulty breathing, swelling, hypotension, and cardiovascular collapse. Anesthesia providers are trained to recognize the signs of anaphylaxis swiftly and respond with prompt and targeted interventions. These may include stopping the administration of the suspected allergen, administering epinephrine, providing supportive measures such as intravenous fluids, and ensuring adequate ventilation.
Preventive measures involve thorough pre-operative assessments to identify potential allergies and employing alternative medications when needed. The unpredictability of allergic reactions necessitates constant vigilance and preparedness within the operating room, emphasizing the importance of comprehensive allergy histories and ongoing education for the entire surgical team. Prompt and effective management of anaphylaxis is paramount to ensure patient safety and mitigate the potentially severe consequences of this rare intraoperative complication.
Hypoxia and Other Respiratory Complications
A condition characterized by low oxygen levels in the body, hypoxia can result from factors such as airway obstruction, respiratory depression, or inadequate ventilation. Other respiratory complications may include bronchospasm, atelectasis, or pulmonary aspiration. Anesthesia providers use various measures to prevent these complications, including proper airway management, administration of supplemental oxygen, and vigilant monitoring of respiratory parameters. Endotracheal intubation and mechanical ventilation may be employed to secure and maintain the airway during certain procedures.
Timely recognition of these complications allows for immediate corrective actions, such as adjusting ventilation parameters, administering bronchodilators, or addressing airway concerns. The goal is to ensure optimal oxygenation and ventilation to prevent hypoxia and minimize the risk of adverse respiratory events during the intraoperative phase. Continuous assessment and proactive measures underscore the commitment of anesthesia providers to maintaining patient safety in the complex and dynamic environment of the operating room.
Hypotension/Hypertension and Other Cardiac Complications
Hypotension (low blood pressure) may result from factors such as excessive vasodilation, blood loss, or inadequate fluid replacement, potentially leading to compromised organ perfusion. Conversely, hypertension (high blood pressure) can be triggered by factors such as pain, anxiety, or a heightened sympathetic response to surgery. Anesthesia providers employ various strategies to maintain hemodynamic stability, including fluid administration, vasopressor or inotropic support, and careful titration of anesthetic agents. Continuous blood pressure, heart rate, and electrocardiogram monitoring is fundamental in the early detection of cardiac complications. Additionally, patients with pre-existing cardiac conditions may need clearance from their cardiologist before any surgical procedure.
Fluid and Electrolyte Imbalances
Fluid and electrolyte imbalances are potential intraoperative complications that require anesthesia providers to maintain physiological equilibrium and support optimal organ function. Surgical procedures can lead to shifts in fluid balance due to factors such as blood loss, third-space losses, or changes in vascular permeability. Anesthesia providers carefully monitor and manage fluid administration to prevent hypovolemia or fluid overload. Electrolyte imbalances, including disturbances in sodium, potassium, and calcium levels, may arise during surgery and impact cardiac, neuromuscular, and renal function. Regular assessment and correction of electrolyte levels are essential components of anesthesia care. Strategies such as intravenous fluid therapy, blood product transfusions, and the administration of electrolyte solutions are employed to address imbalances promptly. Advanced monitoring technologies, including arterial blood gas analysis and laboratory tests, aid in the real-time assessment of fluid and electrolyte status.
Residual Muscle Paralysis
Residual muscle paralysis, also known as postoperative residual neuromuscular blockade, is a potential intraoperative complication associated with the use of neuromuscular blocking agents (NMBAs) during surgery. These drugs induce muscle relaxation, facilitate intubation, and improve surgical conditions. However, incomplete reversal or prolonged effects of NMBAs can lead to residual muscle weakness and compromise respiratory function in the postoperative period, resulting in hypoxia or difficulties in spontaneous respiration. Anesthesia providers utilize neuromuscular monitoring techniques, such as train-of-four (TOF) monitoring (Figure 26.5), to assess the degree of muscle blockade and guide the administration of reversal agents like neostigmine or sugammadex. Ensuring complete recovery of neuromuscular function is crucial for patient safety and is part of the comprehensive approach to preventing postoperative respiratory issues.
Hypothermia
A patient’s core body temperature dropping below the normal range, called hypothermia, is a potential intraoperative complication. Hypothermia can adversely affect metabolic processes, coagulation, and immune function, potentially leading to complications such as surgical site infections and delayed recovery. Surgical procedures, especially those involving prolonged exposure or open body cavities, can cause heat loss. Anesthesia providers mitigate the risk of hypothermia through the use of warming blankets, forced-air warming systems, and heated intravenous fluids. Maintaining normothermia is a key aspect of perioperative care, as it not only supports optimal physiological function but also enhances patient comfort and facilitates a smoother recovery.
Malignant Hyperthermia
The rare but potentially life-threatening intraoperative complication characterized by a hypermetabolic response to certain drugs, most notably volatile anesthetics and succinylcholine is called malignant hyperthermia (MH). MH manifests as a rapid and uncontrolled increase in body temperature, muscle rigidity, and a cascade of metabolic changes. The condition is primarily triggered by a genetic predisposition and affected individuals may not be aware of their susceptibility. Anesthesia teams undergo rigorous training to respond effectively to MH and must maintain a high level of vigilance to recognize the early signs. Common signs and symptoms include:
- Cardiac dysrhythmias
- Changes in CO2 absorbance (temperature, color)
- Hypercarbia (excessive amounts of carbon dioxide in the blood)
- Hyperkalemia, hypercalcemia, lactic acidemia
- Hypoxia and dark (desaturated) blood in the operative field
- Metabolic and respiratory acidosis
- Muscle stiffness or rigidity
- Myoglobinuria (presence of myoglobin in the urine indicating muscle hypoxia)
- Peripheral mottling, cyanosis, or sweating
- Rising body temperature (1°C–2°C every 5 minutes)
- Pronounced elevation in creatine kinase level
- Tachycardia
- Tachypnea (may not be seen in a paralyzed patient)
- Unstable or elevated blood pressure
Immediate cessation of triggering agents, administration of dantrolene to mitigate the hypermetabolic state, and supportive measures such as cooling interventions are crucial in managing MH. Early detection and swift intervention are needed to prevent severe complications, including organ failure and death.
Neurological Problems
Neurological problems pose potential intraoperative challenges requiring careful management by anesthesia providers. Patients with pre-existing cognitive conditions, such as dementia, may experience heightened vulnerability during surgery, necessitating a tailored approach to minimize perioperative cognitive decline. Other potential complications include prolonged awakening and paresthesia.
Prolonged awakening, although rare, can be attributed to various factors, including drug interactions, individual patient response, or incomplete metabolism of anesthetic agents. Anesthesia providers diligently monitor patients during the emergence phase to ensure timely recovery and address any issues contributing to delayed awakening. Physical signs include:
- Delayed responsiveness: the patient takes longer than expected to respond to verbal commands or physical stimuli
- Reduced consciousness: the patient remains in a stuporous or semi-conscious state for an extended period
- Slowed reflexes: the patient exhibits decreased or sluggish reflexes that persist longer than usual
- Impaired breathing: the patient exhibits shallow, irregular, or weaker than normal breathing patterns for an extended duration
- Low blood pressure: the patient exhibits low blood pressure longer than anticipated post-anesthesia
- Prolonged muscle weakness: the patient exhibits muscle relaxation and/or the inability to move or respond appropriately
- Paresthesia: the patient complains of abnormal sensations such as tingling or numbness; may occur due to nerve compression, positioning, or other factors related to the surgical procedure
Nurses must have a comprehensive understanding of each patient’s medical history, and employ vigilant monitoring and proactive measures to optimize the overall safety and well-being of patients undergoing surgery.