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Intraoperative Nursing Introduction Today’s class: – – – – The OR environment Safety in the OR Nursing measures Medications & effect on patients Intraoperative Phase Major nursing goal: help the patient make it through surgery without injury A team effort Surgical Team MEMBERS OF THE SURGICAL TEAM: Patient Holding Area Nurse Circulating nurse Scrub role Surgeon Registered nurse first assistant Anesthesiologist, anesthetist Patient Holding Area Nurses Patient waits here until OR Greet patient Review medical record/pre-op checklist Verify consent forms are signed Document risk assessment Assesses physical/emotional status Gives emotional support Answers questions Provides extra education PRN Marking Patient prior to surgery Circulating Nurse RN Manager of that OR suite Sets up the room – supplies, blood products, etc. Gathers and inspects all equipment Prepares the OR bed Meets, greets, identifies patient Transfers Pt to OR bed, positions Monitors aseptic technique and watches for breaks Greets patient, assists with positioning Coordinates xray, lab Assists anesthesiologist as he/she induces patient Assists with documentation including: – Count of all sponges, sharps, and instruments Notifies PACU of arrival time and any special needs Scrub Role RN,LPN, OR technician, Certified Surgical Technologist (CST) Sets up sterile field Drapes patient Hands sterile instruments, sponges, sutures, etc., to surgeon Aids in gowning and gloving Assists with sponge, needle, and instrument counts Observes team for breaks in aseptic technique This role also done by: – Operating room technicians (ORT’s) – Certified Surgical technologists (CST’s) Surgeon and Surgical Assistants Surgeon – Heads the surgical team – Makes major decisions – Performs surgery Surgical assistants – intern, resident, med student, another MD, PA, CRNFA, or surgical technologist – Help expose operative site » Hold retractors » Suction wound » Cut tissue » Suture » Dress wounds RN First Assistant Assist surgeon Anesthesia Providers Anesthesiologist: – MD who specializes in giving anesthetic agents Certified Registered Nurse Anesthetist CRNA: – RN who has graduated from accredited nurse anesthesia program – Supervised by anesthesiologist, surgeon, dentist, or podiatrist Duties: – – – – – Administers anesthesia Evaluates patient pre-operatively Keeps patient alive during surgery! Alerts surgeon to any problems Monitors VS, I & O, cardiopulmonary function OR Nursing Staff PHYSICAL ENVIRONMENT Pre-op Holding Area – Pt waits in here until surgery – IV started, assessment – In some hospitals, family can stay with pt until time to go to OR Operating Room – – – – – Environmentally controlled Temperature 68 - 75 degrees Restrict # of people Wear special clothes, booties, cap, etc. Room cleaned inbetween cases with detergent germicide Operating Room Minimally Invasive and Robotic Surgery Health Hazards Associated with the Surgical Environment Exposure to blood/body fluids Lazer risk Exposure to latex, radiation, toxic agents Potential for Infection Prevention of Infection Surgical environment – Unrestricted zone – Semirestricted zone – Restricted zone Surgical asepsis Environmental controls Surgical Asepsis Surgical Scrub, Gowning, and Gloving Nursing Management in the Operating Room Provide emotional care – Greet patient at door; help patient to feel safe and secure – If awake during surgery -> support, explain and reassure patient – During initial stage of anesthesia, stand at bedside, touch shoulder, hold hand, etc. Provide Safety surgical asepsis send correct speciman correct sponge count Assist with Surgical Positions Prevent Perioperative Positioning Injury Interventions include: Proper body position Pad bed with foam or silicone gel pads Properly place grounding pad Prevent obstruction of: – circulation, – respiration, and – nerve conduction Good access to surgical site Prevent infection of wound Assess patient for risk Do skin prep Maintain sterile technique Use of Plastic adhesive drapes Skin closures, sutures and staples, nonabsorbable sutures Common Skin Closures Insertion of drains Application of dressing Prevent Hypoventilation Continuous monitoring (every 5 minutes) of: – – – – Breathing Circulation Cardiac rhythms Blood pressure and heart rate Continuous presence of an anesthesia provider Prevent client heat loss – apply warming blanket after surgery Transfer patient from the operating room table to a stretcher ADMINISTRATION OF ANESTHETICS Anesthetics Agents that depress the central nervous system (CNS) – Depress consciousness – Lose ability to respond to sensory stimulation (including pain) – Muscle relaxation Classifications General anesthesia Local anesthesia GENERAL ANESTHESIA Administering a combination of several different drugs to achieve the following goals: – – – – Analgesia (loss of pain perception) Unconsciousness Amnesia Block the body’s reflexes Ideal result: – Best effects with the fewest adverse effects. Four Stages of General Anesthesia Stage 1—analgesia stage – No pain but still awake Stage 2—excitement stage – Excitement, often combative – Many signs of sympathetic stimulation (tachycardia, ↑ RR, BP changes) Stage 3—surgical anesthesia stage – Skeletal muscles relax, RR becomes regular, progressive loss of eye reflexes, pupils dilate – Can do surgery in this stage Stage 4—medullary paralysis – Danger! CNS depression; patient can die Also 3 phases: Induction – from beginning of anesthesia to Stage 3 Maintenance – stage 3 completion Recovery – DC of anesthesia until patient has awakened and communicated Administration of General Anesthesia Inhalation IV injection Balanced anesthesia – Combination of IV drugs and inhalation agents used to obtain specific effects One Example: – – – – thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation Adjuncts to general anesthetic agents: – hypnotics, opioid analgesics, neuromuscular blocking agents Handout Inhalation Agents Volatile liquids or gases that are: – Vaporized in oxygen – Inhaled to induce anesthesia Advantages: – Easy to administer – Can rapidly excrete by ventilation Disadvantage: – May irritate lungs, cause coughing Inhalation Agents - volatile liquids Inhaled Gases (“carrier” gases) Nitrous Oxide - “laughing gas” – most widely used – used to deliver inhalation agent to patient’s lungs – Helps to increase effectiveness of volatile liquids so less is needed Intravenous Anesthetics Sedative-hypnotics Barbiturates Benzodiazepines Barbiturates Two most frequently used barbiturates used: – thiopental (Pentothal) – methohexital (Brevital) How barbiturates work: – Increase cell’s affinity for GABA, a neurotrnsmitter that brings us peace and tranquility GABA quiets cell firing. GABA Neuron Benzodiazepines Most commonly used: – Midazolam (Versed) – diazepam (Valium) cause amnesia decrease anxiety Neuromuscular Blocking Agents (NMBA) Block transmission of nerve impulses - create muscle relaxation Used to maintain controlled ventilation during surgery Succinylcholine – Paralyzes quickly, is gone quickly (four - eight minutes) – For ET intubation – Causes complete respiratory paralysis – Does not cause sedation, does not relieve pain! Antiemetics Prevent and treat nausea and vomiting (most common side effect of anesthesia) Examples: – droperidol (Inapsine) – metoclopramide (Reglan) GENERAL MECHANISM OF ACTION OF INHALED & IV ANESTHETICS Easily cross blood-brain barrier Concentrate in nerve cell membranes Overall effect: orderly and systematic reduction of sensory & motor CNS functions Therapeutic doses: minimal depression of vital functions Overdose: death due to circulatory & respiratory failure Side Effects & Adverse Effects Not as many as in the past Dose dependant Vary with each drug Most common side effects Myocardial depression Respiratory depression Complications from General Anesthesia Malignant hyperthermia Overdose Unrecognized hypoventilation Complications of specific anesthetic agents Complications of intubation Malignant Hyperthermia Cause: – inherited defect of skeletal muscle; stimulated by muscle relaxants or anesthetic agent. – Calcium (inside the cells) increases causing increased metabolic rate Signs and symptoms: – – – – Tachycardia (150) increased temperature (105) muscle rigidity end stage is cardiac arrhythmias, vascular collapse, death Mortality rate: 50% Treatment – First - STOP the anesthetic agents and give 100% oxygen – Give Dantrolene IV (to block release of calcium) – Cool the body slowly - ice packs, chilled IV or irrigation fluids, cold sponge bath – Foley – IV drugs - Na Bicarb – Monitor and treat arrhythmias (Lidocaine) May occur 10-20 minutes after induction, or up to 48 hours after OR. May recur up to 3 days after the first episode. Important to get good history prior to OR Local Anesthesia Briefly disrupts sensory nerve impulse transmission from a specific body area or region Delivered topically and by local infiltration Patient remains conscious and able to follow instructions Regional Anesthesia Type of local anesthesia Blocks multiple peripheral nerves in a specific body region – – – – Field block Nerve block Spinal block Epidural block Nerve Block Sites Spinal and Epidural Anesthesia Complications of Local or Regional Anesthesia Anaphylaxis Incorrect delivery technique Systemic absorption Overdose Local complications Treatment of Complications Establish open airway. Give oxygen. Notify the surgeon. Fast-acting barbiturate is usual treatment. Epinephrine for unexplained bradycardia. Gerontologic Considerations Elderly patients at increased risk for complications of surgery, anesthesia due to: – Multiple health issues – Aging heart, lungs – Decreased homeostatic mechanisms – Changes in responses to drugs due to aging changes (decreased renal function) – Changes in body composition of fat, water Nursing Interventions for the Patient in the Intraoperative Period Reduce anxiety Reduce latex exposure Prevent intraoperative positioning injuries Protect patient from injury Serve as patient advocate Monitor, manage potential complications Protect the Patient from Injury Patient identification Correct informed consent Verification of records of health history, exam Results of diagnostic tests Allergies (include latex allergy) Monitor, modify physical environment Safety measures (grounding of equipment, restraints, not leaving a sedated patient) Verification, accessibility of blood