MS.

WAYNE

CLINICAL INSTRUCTOR

BONGAT, MARY GRACE S.

NURSING STUDENT

INTRAOPERATIVE PHASE
Begins when the clients transferred to operating table and ends when the
clients is admitted to the post anesthesia care unit or RR.
INTRAOPERATIVE NURSING
Nursing action related to this phase include a variety of specialized
procedures designed to create and maintain a safe and therapeutic
environment for the client and health care personnel.

Operation team members

Surgeon-

Anesthesiologist-

Scrub nurse-assist the surgeon

Circulating nurse-assist scrub nurses and the surgeon .they help

position the client for the operation and often position the needed
equipment. obtain additional supplies as needed, arrange lighting and so
on.

DRAPING
General. Draping is another of the precision routines performed in the OR.
Surgical draping of the patient is the placing of sterile coverings on him so
that only the operative site is exposed. Thus,

the skin areas that have not been prepared for surgery are covered in order
that they will not contaminate any sterile items. The sterility of drapes
depends upon their remaining dry and undisturbed; therefore, the placing of
drapes is the last procedure done prior to making the surgical incision. In
addition to the patient, the furniture to be used within the immediate
surgical area must be covered with sterile drapes to prevent contamination
of the wound.
b.  Purpose. The purpose of draping is to create a sterile field by means of
the appropriate and careful placement of linen before surgery begins and to
maintain the sterility of surfaces on which sterile instruments and gloved
hands may be placed during the operation. These requirements presuppose
that all drapes are well secured with towel clips (where necessary) according
to the accepted procedure to prevent disarrangement and contamination,
and that the nonsterile anesthetist and the area required for him are
excluded from the sterile area by a drape-covered screen.

c.  Extent of Draping.

(1)  Thickness of drapes. One drape (two thicknesses of material) provides

an acceptable cover for a sterile field under usual conditions. More than two
thicknesses may be required, however, especially in those areas where
either instruments or sponges are laid if there are possible sources of
contamination, such as moisture, which may seep through to an unsterile
surface beneath. Too many layers of drapes over a patient are detrimental
to him because they cause him to perspire profusely. In addition, the
excessive perspiration may soak through the drapes, thus contaminating
them.

(2)  Area draped. The sterile drapes must extend over the sides and ends of
the tables to prevent contamination of either the sterile instruments or the
gowns worn by members of the team.

d. Responsibility for Draping.

(1)  Scrub. The scrub is responsible for providing an area large enough for
all sterile supplies to be used. He stacks the drapes for the patient, prepares
the operating table in the proper order of their use, and refolds towels as
necessary for the case and handing these, with towel clips, to the surgeon. If
the surgeon has no medical officer assistant for the case, the specialist helps
him drape the patient.

(2)  Surgeon. The surgeon is responsible for the draping of the patient.
When the surgeon has scrubbed and put on gown and gloves, he places the
towels (securing them with towel clips) outlining the incision area, after the
skin has been prepped and has dried. This completed, the surgeon may
choose to place the drapes himself with the help of his assistant or to
supervise their placement by his assistants and the scrub.

e.  Types of Drape Material.

(1)  Synthetic and paper. Absorbent and nonabsorbent synthetic and paper
disposable drapes are available in presterilized packages. The most popular
ones are soft, lint-free, lightweight, compact, non-irritating and static free.
They prevent heat retention by patients because of their lightness, yet they
do not usually require reinforcement to prevent moisture seepage. The main
disadvantage of synthetic drapes is that solvents, volatile (evaporating)
liquids, and sharp instruments may easily penetrate the barrier and cause
contamination. The high cost is largely offset by the elimination of
laundering, folding, and sterilizing that is necessary for linen drapes.

(2)  Impermeable plastic drapes. Impermeable (not permitting passage,

especially of liquid) plastic sheeting in various types and sizes is available
with an adherent coating. Since it adheres tightly to the skin, the initial skin
incision is made through it; therefore, it may be used instead of the skin
towels and clips, especially since it serves as an excellent barrier at the
incisional site and the surrounding area. A

Vi-drape is an example of an impermeable plastic drape. Impermeable

plastic drapes are especially useful for draping irregular surfaces, such as
neck and ear regions, or limbs and joints. This type of drape may also be
used to isolate a contaminated area (such as the stoma of a colostomy) from
the operative site. The plastic drape isolates the wound completely and
prevents the contact of sterile materials with the patient's skin. When used,
the plastic adherent drape is applied first, and the remaining drapes are
placed in the usual manner.

(3)  Linen. The linen drapes most frequently used include:

(a)  Hand towels used to outline the incision area.

(b)  Sheets (ordinary bed sheets) are fan folded to cover the sterile field or
to extend the sterile area.

(c)  Fenestrated sheets made in various sizes and with slits or windows of a
size sufficient to accommodate the length of the proposed incision.

(d)  Stockinette used as draping on limbs.

(e)  Perineal sheets used with the patient in lithotomy position. They have
leggings sewn on them to cover the legs.

f.  Basic Requirements for Drapes. Drape material must be free from holes
and free from worn or thin areas. A drape must be of sufficient thickness,
and it must be fanfolded, so that it can be opened quickly and placed
without contamination.

g.  Use of Packs. The use of linen packs for various types of surgery
(laparotomy, perineal, or orthopedic) saves time and effort as compared to
opening individual packages of the many items needed. All articles in a linen
pack should be stacked on the sterile table in the order of their use as a
further timesaving device.

h.  Procedure for Draping. Procedures for draping may vary somewhat
among hospitals depending on the types and the amount of linens available,
but the principles pertaining to the sterility and efficiency of the draping
procedure remain the same. These principles are set forth below.

Incision care refers to a series of procedures and precautions related to

closing a wound or surgical incision; protecting the cut or injured tissues
from contamination or infection; and caring properly for the new skin that
forms during the healing process. Incision care begins in the hospital or
outpatient clinic and is continued by the patient during recovery at home .

Purpose

There are several reasons for caring properly for an incision or wound. These

include:

 lowering the risk of postoperative complications, particularly infection

 avoiding unnecessary pain or discomfort

 minimizing scarring

 preventing blood loss

Proper care of an incision begins with knowing what material or technique

the surgeon used to close the cut. There are four major types of closure

used in Canada and the United States as of 2003.

SURGICAL SUTURES. Sutures, or stitches, are the oldest method still in

use to close an incision. The surgeon uses a sterilized thread, which may be

made of natural materials (silk or catgut) or synthetic fibers, to stitch the

edges of the cut together with a special curved needle. There are two major

types of sutures, absorbable and nonabsorbable. Absorbable sutures are

gradually broken down in the body, usually within two months. Absorbable

sutures do not have to be removed. They are used most commonly to close

the deeper layers of tissue in a large incision or in such areas as the mouth.

Nonabsorbable sutures are not broken down in the body and must be

removed after the incision has healed. They are used most often to close the

outer layers of skin or superficial cuts.

Sutures have several disadvantages. Because they are made of materials

that are foreign to the body, they must be carefully sterilized and the skin

around the incision cleansed with Betadine or a similar antiseptic to minimize

the risk of infection. Suturing also requires more time than newer methods

of closure. If the patient is not under general anesthesia, the surgeon must

first apply or inject a local anesthetic before suturing. Lastly, there is a

higher risk of scarring with sutures, particularly if the surgeon puts too much
tension on the thread while stitching or selects thread that is too thick for

the specific procedure.

SURGICAL STAPLES. Surgical staples are a newer method of incision

closure. Staples are typically made of stainless steel or titanium. They are

used most commonly to close lacerations on the scalp or to close the outer

layers of skin in orthopedic procedures. They cannot be used on the face,

hand, or other areas of the body where tendons and nerves lie close to the

surface. Staples are usually removed seven to 10 days after surgery.

Staples are less likely to cause infections than sutures, and they also take

less time to use. They can, however, leave noticeable scars if the edges of

the wound or incision have not been properly aligned. In addition, staples

require a special instrument for removal.

STERI-STRIPS. Steri-strips are pieces of adhesive material that can be

used in some surgical procedures to help the edges of an incision grow

together. They have several advantages, including low rates of infection,

speed of application, no need for local anesthesia, and no need for special

removal. Steri-strips begin to curl and peel away from the body, usually

within five to seven days after surgery. They should be pulled off after two
weeks if they have not already fallen off. Steri-strips, however, have two

disadvantages: they are not as precise as sutures in bringing the edges of

an incision into alignment; and they cannot be used on areas of the body

that are hairy or that secrete moisture, such as the palms of the hands or

the armpits.

LIQUID TISSUE GLUES. Tissue glues are the newest type of incision

closure. They are applied to the edges of the incision and form a bond that

holds the tissues together until new tissue is formed. The tissue glues most

commonly used as of 2003 belong to a group of chemicals known as

cyanoacrylates. In addition to speed of use and a low infection rate, tissue

glues are gradually absorbed by the body. They are less likely to cause

scarring, which makes them a good choice for facial surgery and other

cosmetic procedures. They are also often used to close lacerations or

incisions in children, who find them less frightening or painful than sutures

or staples. Like Steri-strips, however, tissue glues cannot be used on areas

of high moisture. They are also ineffective for use on the knee or elbow

joint.

POSITION OF THE PATIENT

SURGICAL INSTRUMENT