med surg chapter 019

Intraoperative

Care Chapter 19

Intraoperative Care•Historically, took place in OR• Current trend to ↓ in-hospital surgery and ↑ ambulatory procedures•Healthier patients•Shorter procedures

Intraoperative Care• Specialties with highest numbers of surgical patients•Ophthalmology•Gynecology•Plastic surgery•Otorhinolaryngology•Orthopedic surgery•General surgery (e.g., hernia repair)

Physical Environment• Surgical suite•Controlled environment•Designed to minimize spread of infection•Allows smooth flow of patients, personnel, and instruments/equipment

Physical Environment•Unrestricted areas•Personnel in street clothes interact with those in scrubs• Holding area• Locker room• Information areas

Nursing stationControl desk

Physical Environment• Semirestricted areas•Peripheral support areas and corridors with only authorized staff•Must wear surgical attire and cover all head and facial hair

Physical Environment•Restricted areas•Operating rooms•Scrub sink areas•Clean core•Surgical attire, head covers, and masks required

Physical Environment•Holding area•Waiting area inside or adjacent to surgical suite• Final identification and assessment• Friends/family allowed

Case Study• M.C., a 56-year-old male, comes to the surgical suite with his girlfriend the morning of his scheduled surgery to replace his left knee.

• He has a diagnosis of osteoarthritis of his left knee, as well as a history of hypertension.

iStockphoto/Thinkstock

Physical Environment•Holding area•Surgical Care Improvement Project (SCIP) measures to implement here• Drug administration• Patient warming• Application of sequential compression devices (SCDs)• Minor procedures

Physical Environment•Holding area•National Patient Safety Goals (NPSGs) require a preprocedure process, including:

Verification of relevant documentation

Required blood products and equipment

Diagnostic and radiology test Procedure site marked

Physical Environment•AOD area•Admission, observation, and discharge area• Early morning admissions

Outpatient surgerySame-day admissionInpatient holding

Physical Environment•Operating room•Geographically, environmentally, and bacteriologically controlled•Restricted inflow and outflow of personnel •Preferred location is next to PACU and surgical ICU

Traditional Operating Room

Physical Environment•Operating room • Filters•Controlled airflow•Positive air pressure•UV lighting•No dust-collecting surfaces•Materials resistant to corroding

Physical Environment•Adjustable, easy-to-clean, and easy-to-move furniture is used• Equipment is checked for functioning and electrical safety• Lighting provides low to high intensity for precise view of surgical site• Communication system is used

Surgical Team• Perioperative nurse• Is a registered nurse (RN)•Prepares room with team•Serves as patient advocate throughout surgical experience•Maintains patient safety, privacy, dignity, confidentiality

Surgical Team• Scrub nurse• Follows designated scrub procedure•Gowned and gloved in sterile attire•Remains in sterile field

Surgical Team• Circulating nurse•Not scrubbed, gowned, or gloved•Remains in unsterile field •Documents

Surgical Team• Communication•Situation•Background•Assessment•Recommendations

• M.C. will soon be transported to the OR for his procedure to begin. • His left knee has been marked by the surgeon. • He has an antiembolic stocking and SCD on his right leg, an IV of D5 ½ NS infusing in his right hand, and physician orders for Ancef 1 g IV and insertion of a urinary catheter.

Case StudyiStockphoto/Thinkstock

Surgical Team• LPN or surgical technician•Performs scrubbed or circulating function•Passes instruments and implements other technical functions during procedure•Supervised by RN

Surgical Team• Surgeon•Physician who performs the procedure• Is responsible for• Preoperative medical history• Physical assessment• Patient safety• Postoperative management

Surgical Team• Surgeon’s assistant can be a physician, RN, or PA who functions in assisting role•Holds retractors•Assists with homeostasis and suturing•May perform portions of procedure under direct supervision

Surgical Team•Registered Nurse First Assistant (RNFA)•Must have formal education•Works collaboratively with the surgeon, patient, and surgical team• Handles tissue• Uses instruments• Provides exposure to surgical site• Assists with homeostasis• Performs suturing

Case Study• The anesthesiologist meets with M.C. in the holding area.• The purpose is to assess and obtain informed consent for the general anesthesia to be provided during his surgery.

Surgical Team•Anesthesia care provider (ACP)•Administers anesthesia•Anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA)•Maintenance of physiologic homeostasis throughout intraoperative period

Surgical Team•Anesthesia care provider (ACP)•Prescribes preoperative and adjunctive medicines•Monitors cardiac and respiratory status and vital signs throughout procedure

Nursing Management•Before surgery•Psychosocial assessment•Cultural and spiritual assessment •History and physical assessment

Nursing Management•Before surgery•Chart review• History and physical examination• Urinalysis• CBC• Serum electrolytes• Chest x-ray• ECG

Nursing Management•Admitting patient•Greeting• Extension of human contact and warmth•Proper identification

Nursing Management•Admitting patient•Complementary and alternative therapies• Decrease anxiety• Promote relaxation• Reduce pain• Accelerate healing process

Case Study

• When M.C. arrives in the holding area, he appears anxious and answers questions with reluctance. • He shares that this is the first time he is having surgery. • He also reports pain of 6 in his right knee on a 0–10 scale.

Nursing Management•Admitting patient•Reassessment• Last-minute questions•Review of chart • Final questioning about valuables, prostheses, contacts, last intake of food/fluid

Nursing Management•Room preparation•Surgical attire worn by all persons entering OR suite• Electrical and mechanical equipment checked for proper function

Nursing Management•Room preparation•Aseptic technique practiced when placing instruments• Counts• Functions of team members delineated

Nursing Management• Transferring patient•Patient transported into OR after preparation•Sufficient number of staff to lift, guide, and prevent patient falls, as well as injury to staff•Caution with monitor leads, IVs, and catheters•Wheels locked

Nursing Management• Scrubbing, gowning, and gloving•Cleanse hands and arms by scrubbing with detergent and brush• Eliminates dirt and oil• Decreases microbes• Inhibits rapid regrowth of microorganisms

Nursing Management• Scrubbing, gowning, gloving•Standard procedure for personnel•Waterless products are sometimes used•Sterile gown and gloves are put on after scrub

Nursing Management•Basic aseptic technique•Center of sterile field is site of surgical incision•Only sterilized items in sterile field• Protective equipment• Face shields, caps, gloves, aprons, and eyewear

Nursing Management•Assisting anesthesia care provider•Understand mechanism of anesthetic administration and pharmacologic effects of the agents•Know location of emergency equipment and drugs in the OR

Nursing Management•Assisting anesthesia care provider•Circulating nurse may place monitoring devices on patient•Remain at patient’s side to ensure safety

Nursing Management• Safety considerations• Fire•Smoke particles•Universal protocol•Surgical time-out

Nursing Management• Positioning of patient•Accessibility of operative site•Administration and monitoring of anesthetic agents•Maintenance of airway

Nursing Management• Positioning of patient•Correct skeletal alignment•Prevent pressure on nerves, skin, bony prominences, or eyes•Provide for adequate thoracic excursion

Nursing Management• Positioning of patient•Prevent occlusion of arteries and veins•Provide modesty in exposure•Recognize and respect needs such as pain or deformities

Nursing Management• Positioning of patient•Prevent injury• Patient will not feel pain impulses because of anesthesia• Secure extremities• Provide adequate padding and support

Case Study

• M.C. is transferred to the OR table.

• The circulating nurse begins to prepare him for the surgery.

• Preventing hypothermia•Closely monitor temperature•Apply warming blankets

Nursing Management

Nursing Management• Preparing surgical site•Scrub or clean around the surgical site with antimicrobial agents• Use a circular motion from clean to dirty area• Allow to fully dry•Hair may be removed with clippers

Case Study•With M.C. positioned for surgery, the circulating nurse begins to prepare his leg for surgery.

Nursing Management•After surgery•Perioperative nursing data set (PNDS) reflects standards of nursing care in any perioperative setting•ACP and perioperative team member take patient to PACU and give report•Handoff procedure

Case Study• M.C.’s surgery is completed and he is transferred to the PACU.• He has a drain in his left knee.• His left leg is wrapped with an elastic bandage from ankle to thigh. • He has a non-rebreather oxygen mask on at 100% and his IV continues to infuse at 100 mL/hr.

Anesthesia

Anesthesia•Anesthetic technique and agents are selected by the ACP that consider•Physical and mental status•Allergy and pain history• Expertise of the ACP• Factors related to operative procedure

Anesthesia•American Society of Anesthesiologists (ASA) Physical Status Scale•Scale of 1 to 6•Represents patient immediately before surgery• 1= healthy• 6= brain-dead

Classification of Anesthesia•Monitored Anesthesia Care (MAC)•Used for diagnostic or therapeutic procedures in or outside the OR• Includes varying levels of sedation, analgesia, and anxiolysis•Must be administered by an ACP

Classification of Anesthesia•Moderate sedation•Procedures performed outside the OR•Does not require an ACP•May be administered by an RN under direct supervision of a physician

Classification of Anesthesia•General anesthesia• Total IV anesthesia (TIVA)• Inhalation• Technique of choice for surgeries with significant duration or that require relaxation/uncomfortable position/control of ventilation•Balanced technique with adjunctive drugs

Classification of Anesthesia•General anesthesia• IV agents• Beginning of virtually all general anesthesia• Induce pleasant sleep• TIVA

Classification of Anesthesia•General anesthesia• Inhalation agents• Volatile liquids or gases• Easy administration and rapid excretion• Irritating to respiratory tract• Once initiated, use ET tube or LMA

Classification of Anesthesia•General anesthesia•Rarely use only one agent• Adjuncts•Dissociative anesthesia• Ketamine (Ketalar)

Classification of Anesthesia•Adjuncts to general anesthesia•Opioids• Sedation and analgesia• Induction and maintenance intraoperatively• Pain management postoperatively• Respiratory depression

Classification of Anesthesia•Adjuncts to general anesthesia•Benzodiazepines• Premedication for amnesia• Induction of anesthesia• Monitored anesthesia care

Classification of Anesthesia•Adjuncts to general anesthesia•Neuromuscular blocking agents• Facilitate endotracheal intubation• Relaxation/paralysis of skeletal muscles• Interrupt transmission of nerve impulses at neuromuscular junction

Classification of Anesthesia•Neuromuscular blocking agents• Classified as depolarizing or nondepolarizing muscle relaxants• Duration of effects may be longer than the procedure• Reversal agents may not be effective in eliminating residual effects

Classification of Anesthesia•Neuromuscular blocking agents• Observe closely for airway patency and adequacy of respiratory muscle movement• Lack of movement or poor return of reflexes and strength may indicate need for ventilator

Classification of Anesthesia•Adjuncts to general anesthesia•Antiemetics• Prevent nausea and vomiting associated with anesthesia

Classification of Anesthesia• Local anesthesia• Loss of sensation without loss of consciousness• Types• Topical• Ophthalmic• Nebulized• Injectable

Classification of Anesthesia•Regional anesthesia• Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked by administration of local anesthetic•Always injected

Classification of Anesthesia• Local and regional anesthesia• Little systemic absorption• Rapid recovery• Little residual “hangover”•Possible discomfort, hypotension, and seizures• Technical difficulties

Classification of Anesthesia•Regional anesthesia•May assist in administration• Be familiar with drugs• Detailed assessment•Allergies• Likely the result of additives or preservatives

Classification of Anesthesia•Methods of administration• Topical• Apply 30 to 60 minutes before procedure

• Local infiltration• Inject agent into tissues through which incision will pass

Classification of Anesthesia•Methods of administration•Regional nerve block• Inject agent into or around specific nerve or group of nerves

Classification of Anesthesia•Methods of administration•Spinal anesthesia• Injection of agent into CSF of subarachnoid space• Usually below L2• Autonomic, sensory, and motor blockade

Classification of Anesthesia•Methods of administration• Epidural block• Injection of agent into epidural space• Does not enter CSF• Binds to nerve roots as they enter and exit the spinal cord• Sensory pathways blocked but motor fibers intact

Classification of Anesthesia• Spinal and epidural anesthesia•Observe closely for signs of autonomic nervous system (ANS) blockade• Bradycardia• Hypotension• Nausea/vomiting

Gerontologic Considerations•Anesthetic drugs should be carefully titrated•Assess for poor communication•Risk from tape, electrodes, and warming/cooling blankets•Osteoporosis and osteoarthritis• Perioperative hypothermia

Catastrophic Events in the OR•Anaphylactic reactions•Manifestation may be masked by anesthesia•Vigilance and rapid intervention are essential•Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema

Catastrophic Events in the OR•Malignant hyperthermia•Rare metabolic disorder•Hyperthermia with rigidity of skeletal muscles

Catastrophic Events in the OR•Malignant hyperthermia•Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents•Usually occurs under general anesthesia but may also occur in recovery

Catastrophic Events in the OR•Malignant hyperthermia•Other triggers• Trauma• Heat• Stress

Catastrophic Events in the OR•Malignant hyperthermia•Autosomal dominant trait• Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium

• Tachycardia• Tachypnea

Catastrophic Events in the OR•Malignant hyperthermia•Hypercarbia•Ventricular dysrhythmias•Rise in body temperature NOT an early sign•Can result in cardiac arrest and death

Audience Response Question During admission of the patient to the holding area or operating room before surgery, the perioperative nurse musta. Verify the patient’s understanding of

the risks of surgery.b. Ensure the patient’s identity with a

formal identification process.c. Prepare the skin by scrubbing the

surgical site with an antimicrobial agent.

d. Perform a preoperative assessment with a patient history and physical examination.

Audience Response Question During the administration of any regional anesthetic, it is most important that the nursea. Monitor for ascending neurologic

depression and unconsciousnessb. Ensure that airway equipment,

emergency drugs, and monitors are immediately available

c. Monitor the patient’s response to the anesthesia, assessing the extent of loss of sensation

d. Have reversal drugs such as anticholinesterase agents (e.g., neostigmine [Prostigmin]) available in case of respiratory arrest

med surg chapter 019

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