Download Lewis: Medical-Surgical Nursing, 8 th Edition

Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 19: Nursing Management: Intraoperative Care
Key Points – Printable
PHYSICAL ENVIRONMENT OF OPERATING ROOM
 The surgical suite is divided into three distinct areas: unrestricted, semirestricted, and
restricted.
o The unrestricted area is where staff in street clothes can interact with those in
scrub clothing.
o In the semirestricted area, staff must wear surgical attire and cover all head and
facial hair.
o In the restricted area—which includes the operating room (OR), the sink area,
and clean core—masks are required to supplement surgical attire.
 In the holding area, you identify and assess the patient before transferring the patient into
the OR for surgery. Procedures such as inserting intravenous (IV) catheters and arterial
lines and removing casts may occur here.
 The OR, unlike other units, is controlled geographically, environmentally, and
bacteriologically, and it is restricted in terms of the inflow and outflow of staff.
SURGICAL TEAM
 A perioperative nurse is a registered nurse who implements patient care during the
perioperative period. This includes preparing the OR for the patient, serving as the
patient’s advocate during surgery, assessing the patient for additional needs or tasks
before surgery, and educating the patient and caregivers.
 The circulating nurse is not scrubbed, gowned, or gloved and performs activities in the
unsterile field.
 The scrub nurse follows the designated scrub procedure, is gowned and gloved in sterile
attire, and performs activities in the sterile field.
 The registered nurse first assistant works with the surgeon, using instruments, providing
exposure to the surgical site, assisting with hemostasis, and suturing.
NURSING MANAGEMENT: PATIENT BEFORE SURGERY
 Preoperative assessment includes the psychosocial assessment, physical assessment, and
chart review.
 Assessment data important to intraoperative nursing care include the patient’s vital signs,
height, weight, and age; allergies to food, drugs, and latex; integrity and cleanliness of
skin; skeletal and muscle impairments; perceptual difficulties; level of consciousness;
nothing-by-mouth (NPO) status; and any sources of pain or discomfort.
 The task of prepping the patient may be completed preoperatively by nursing assistive
personnel (NAP) or intraoperatively by the circulating nurse, surgeon, or surgical
assistant. Immediately before surgery, a preoperative checklist is completed and
preoperative medications, if ordered, are given.
NURSING MANAGEMENT: PATIENT DURING SURGERY
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Key Points – Printable
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Surgical hand antisepsis is required of all sterile members of the surgical team.
The center of the sterile field is the site of the surgical incision.
The nurse must understand the mechanism of anesthetic administration and the
pharmacologic effects of the agents as well as the location of all emergency drugs and
equipment in the OR area.
Positioning the patient is a critical part of every procedure and usually follows
administration of the anesthetic.
It is the nurse’s responsibility to secure the patient’s extremities, provide adequate
padding and support, and obtain sufficient physical or mechanical help to avoid
unnecessary straining of self or patient.
After surgery, the patient’s response to the nurses’ care is evaluated based on outcome
criteria established during the development of the patient’s plan of care.
ANESTHESIA
 Anesthetic technique and agents are selected by the anesthesia care provider (ACP) in
collaboration with the surgeon and the patient; the ultimate responsibility for the choice
of anesthetic remains the responsibility of the ACP.
 An absolute contraindication of any anesthetic technique is patient refusal.
 The American Society of Anesthesiologists classifies anesthesia according to the effect
that it has on the patient’s sensorium and pain perception. These classifications include
general anesthesia, regional anesthesia, local anesthesia, and local anesthesia with
monitored anesthesia care (MAC).
General Anesthesia
 The technique of choice for patients who are having surgical procedures that are of
significant duration, require skeletal muscle relaxation, require uncomfortable operative
positions because of the location of the incision site, or require control of respiration.
 May be delivered intravenously or by inhalation and maintained by either one or a
combination of the two. A balanced technique, using adjunctive drugs to complement the
induction, is the most common approach used for general anesthesia.
 Nearly all routine general anesthetics begin with an IV induction agent.
 Inhalation agents:
o Administered by an endotracheal tube, a laryngeal mask airway, or a
tracheostomy and enter the body via the lung alveoli.
o Complications of inhalation anesthesia include coughing, laryngospasm,
bronchospasm, increased secretions, and respiratory depression.
 Drugs to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or autonomic
nervous system control are added to an inhalation anesthetic and are termed adjuncts.
Local and Regional Anesthesia
 Advantages of local and regional anesthesia include rapid recovery and discharge with
continued postoperative analgesia without any accompanying cognitive dysfunction. The
inability to precisely match the duration of action of the agents to the duration of the
surgical procedure is a limiting factor.
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Key Points – Printable
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Local anesthesia administered either topically or by injection allows for an operative
procedure to be performed on a particular part of the body without loss of consciousness
or sedation.
Regional anesthesia uses a local anesthetic and is injected near a central nerve (e.g.,
spinal) or group of nerves (e.g., plexus) that innervate a site remote to the point of
injection.
o Spinal and epidural anesthesia are types of regional anesthesia.
o When spinal or epidural anesthesia is used, the patient can remain fully conscious,
receive MAC, or choose general anesthesia.
Local anesthesia with MAC is often used for procedures performed outside of the OR
(e.g., reduction of dislocated joints in the emergency department).
GERONTOLOGIC CONSIDERATIONS: PATIENT DURING SURGERY
 The onset, peak, and duration of anesthetic drugs administered by any route are greatly
altered. Because of this, anesthetic drugs should be carefully titrated when given to older
adults.
 Physiologic changes in aging may alter the patient’s response not only to the anesthetic,
but also to blood and fluid loss and replacement, hypothermia, pain, and the tolerance of
the surgical procedure and positioning.
CATASTROPHIC EVENTS IN OPERATING ROOM
 Anaphylaxis is the most severe form of an allergic reaction, manifesting with lifethreatening pulmonary and circulatory complications. The initial clinical manifestations
of anaphylaxis may be masked by anesthesia.
 Malignant hyperthermia is a rare disorder characterized by hyperthermia with rigidity of
skeletal muscles that can result in death. It occurs in affected people exposed to certain
anesthetic agents. To prevent malignant hyperthermia, it is important for you to obtain a
careful family history and be alert to its development perioperatively.
NEW AND FUTURE CONSIDERATIONS
 Changes in technology and surgical techniques, including minimally invasive and
“bloodless” surgeries, provide new and better treatment modalities for the patient
undergoing surgery.
 Robotic-assisted surgery is now a reality in the OR, and the number of different
procedures that can be performed using robotics is growing.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.