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Surgical Settings

• Surgical settings are evolving as surgical knowledge advances and new equipment evolves.
• Surgical options include both traditional hospital settings and outpatient surgical centers with similar amenities.
• Inpatient settings offer care for patients needing post-operative admittance to a hospital unit.
• Inpatient procedures often involve invasive and long operations needing over 24 hours of monitoring.
• Cardiac surgeries needing ICU care and joint replacements needing complex pain relief are examples of inpatient procedures.
• Hospital admission after surgery may be needed for rehabilitation.
• Outpatient surgery doesn't require admittance to a hospital before or after the procedure.
• Outpatient surgery can occur in freestanding surgery centers or in hospitals, also known as "same-day surgery."
• Outpatient surgery is often less invasive and requires less than 24 hours of monitored recovery.
• Patients are often admitted 2 hours before surgery and discharged straight to their homes.
• Outpatient surgery candidates typically don't have comorbidities or need extra recovery care beyond postanesthesia.
• Successful home recovery requires patients who can learn before discharge, and caregivers present at all times for at least 24 hours
• ENT, oral, and orthopedic surgeries are examples of outpatient surgeries.
• Mastectomies may be done in outpatient settings.
• Ambulatory surgical centers follow the same safety measures include anesthesiologists, sterile environments, and PACUs as inpatient settings.
• Before discharge from outpatient settings, managing pain and understanding recovery are key.
• Freestanding outpatient surgery centers are rapidly expanding due to convenience and flexibility.
• These centers allows greater flexibility in schedules.
• Family members are only separated while the procedure occurs, and can more easily participate in postoperative attention.
• Freestanding sites are also less expensive and offer more face-to-face time with nurses.
• Nurses in outpatient facilities must rapidly assess patient's learning needs due to shorter recovery times and give education before anesthesia takes effect.

Surgical Categories

• Surgery is categorized into diagnostic, curative, restorative, palliative, cosmetic, and transplant.
• Diagnostic surgeries such as exploratory procedures, laparotomies/arthroscopies, and biopsies determine the source of disorders.
• Curative surgeries fix or remove the source of a disorder.
• Restorative surgeries such as total hip replacements, improve function by reconstructing mechanical parts.
• Palliative procedures alleviate pain and improve comfort and quality of life.
• Cosmetic surgery focuses on improving appearance.
• Transplant surgery replaces dysfunctional organs.
• Surgical procedures includes elective, urgent and emergency.
• Elective surgery is chosen for well-being but is not essential.
• Plastic, oral, and orthopedic surgeries are often elective and scheduled at patient's convenience in outpatient settings.
• Urgent surgeries can be scheduled, but may be done later.
• Hysterectomies, laminectomies, and hip or knee replacements are examples of urgent surgeries.
• Emergency surgery, due to its unscheduled nature, is done to save a life or limb, like with gunshot wounds, stabbings, or auto accidents

Sterile Team Members

• Several million individuals worldwide face a surgical procedure each day.
• Surgical patients rely on the surgical team's experience and knowledge.
• An efficiently functioning team in the surgical environment is extremely important, needing respect, harmony, and strong communication.
• Surgical teams include a surgeon, an anesthesia provider, a perioperative RN, and assistive personnel.
• Sterile members are those who scrub in and wear sterile attire, working within the identified sterile field.
• Non-sterile members function outside the identified sterile field.
• Sterile members include surgeons, surgical assistants, and scrub nurses/technologists/OR technicians.
• Sterile team members have responsibility of aseptic technique, controlling the sterile field and preventing microorganism contamination
• The sterile field includes the OR table, the Mayo stand, and instrument table.
• Sterile team members use disinfecting soaps to scrub their hands/arms and arms and wear surgical gowns
• Surgeons lead the surgical team and has the ultimate responsibility for performing the surgery safely.
• Depending on complexity, more than one provider may assist the surgeon, including interns, hospital residents, and other specialists
• Surgical assistants are practitioners having specialized training to assist with procedures.
• Physician assistants, surgical first assistants, nurse practitioners, and RN first assistants can be surgical assistants.
• PAs help licensed providers, assist pre- and postoperatively, and ensure the collection of diagnostic films, records, lab studies, and patient history all while reporting issues to the relevant parties.
• SFAs are certified surgical technologists with extra training who aid by exposing surgical sites, encouraging hemostasis, and performing other technical functions.
• RNFAs or NPs are RNs who have undergone additional perioperative environment training, which varies by state. They function similar to PAs to aid the surgeon during the operation.
• Scrub nurses, surgical technologists, and OR technicians work directly with the surgeon in the sterile field.
• They pass them instruments, sponges, and equipment.
• Scrubs prepare the OR by setting up equipment, sterile drapes, and solutions and assemble both sterile and non-sterile equipment. Also checking functionality
• Scrubs also help the team don sterile attire, count supplies, prepare/dispose of specimens, and assist surgical dressings.
• Scrubs then disassemble the sterile site, clean-up, and restocks the OR.

Nonsterile Team members

• Nonsterile members perform their duties outside the sterile field
• Nonsterile team members includes the anesthesia provider, the circulating RN, unlicensed assistive personnel, and the OR director/coordinator/manager
• Anesthesia providers maintain the physiological status of the patient through the procedure.
• Anesthesia providers may be anesthesiologists (physicians) or CRNAs (advanced practice RNs) who can work independently or with anesthesiologists.
• Anesthesia providers should be actively aware of the surgeon's actions for patient safety.
• Their specific responsibilities are providing smooth anesthesia induction, ensuring the patient's comfort/relaxation, and maintaining/monitoring the patient's vitals.
• The anesthesia provider has contact with the patient during all surgical phases.
• During the preoperative phase, the anesthesia provider meets with the patient, reviews their history/medications, discusses anesthesia options and plans to manage their health during surgery.
• During the intraoperative phase, the anesthesia provider gives anesthetic agents and carefully monitors patient’s vitals.
• Anesthesia agents can be modified to adjust patient's physical state.
• During the recovery phase, anesthesia is stopped, allowing for metabolism of medications and consciousness to return.
• In the postoperative phase, patients are transferred to a PACU or ICU
• Anesthesia care providers maintain respiratory support, manage pain, and monitor vitals as well as approves movement to postsurgical destination
• Circulating RNs observe the procedure for a broad view, ensuring safety of the patient.
• The circulating RNs responsibilities include initial assessment/therapeutic relationship in the preoperative area
• The circulating RNs also assist the anesthesia provider, assist the surgeon and scrub nurse, anticipate needs for equipment and supplies, ensure specimen labeling/analysis, document data, and count used items.
• Unlicensed assistive personnel work for and are accountable to perioperative RNs performing duties like patient transport and positioning assistance.
• Unlicensed assistive personnel also deliver specimens, obtain blood, obtain equipment, and perform housekeeping duties.
• The OR director/coordinator/manager oversees the business aspect of the OR including budgets, staffing, and maintaining efficiency.

Preoperative Assessment

• Priority assessments are essential to safe surgical experience that include preoperative assessment; surgical pause/fire prevention, arm scrub, surgical attire donned, and surgical count completed
• The preoperative assessment should determine patient knowledge, ensure informed consent, determine anxiety reasons, AND obtain relevant patient details.
• The patients knowledge is defined as the patient’s knowledge of the planned surgery, potential complication and interventions.
• The nurse should provide education as appropriate.
• The preoperative nurse confirms consent for surgery, determines the patient’s preferred name and pronoun, clarifies NPO status, determines drugs taken that morning, checks skin, and assesses family support.
• The nurse records allergy status, details metal implants, validates the patient’s religious or cultural preferences, and records the patient’s health history.

Surgical Pause and Fire Risk Assessment

• The surgical pause/time-out verifies patient safety by ensuring correct patient, procedure, surgeon, position, equipment, imaging studies, and antibiotic use.
• The surgical pause will confirm implants and any laterality. and include a fire risk assessment.
• Fire prevention in the OR is important and needs all members of the surgical team
• Standard interventions to prevent fire includes communicating and assessing fire assessments as well as assessment of flammability of all materials.
• Standard interventions to prevent fire also need notifying when high levels of oxygen used, checking electrical equipment, access to water/saline is there, and all heat sources are protected whe not in use
• The NFPA suggests fire drills and training for hospital staff.
• The Joint Commission developed a universal time out and needs active communication along all members of the team
• The surgical procedure can't progress when any questions exist.

Surgical Scrub and Attire

• Communication is best defined as the meaningful exchange of information between individuals or groups.
• There is a need of effective communication in the perioperative setting in order to keep things safe,
• The Joint commission stated that failure of communication is the root cause of medication safey, delays, and wrong surgeries. it is also seen as the second most root cause of post operative and operative.
• AORN provides updated processes needed for team communication.
• Team communication includes hand-offs from stages of care, timeout or the patient and details. and a brief on work that was done or needs fixed
• A surgical scrub is done in the OR to prevent infections.
• Human hands transmit and act as portal to infections, making the warm moist surroundings a bacterial loving area.
• To prevent this, the OR team has proper hygeine and the hand cleaning rules.
• Nails are short, jewelry off and hands washed very well.
• Surgical scrubs start with basic hand washing then moving area scrubs from clean (hand) to less (arm)
• Scrubbing with powerful solutions for 3-5 mins is adequate to remove microorganisms and potential protection if breakage occur
• Alcohol-based hand washes may be used as well
• Proper attire is needed reduce post opp infections
• Scrub attire is for everyone in a scrubbed or not sterile envoironment
• scrubs are the shirts, pants, or dresses work by nurses staff in the theatre
• sterile gown and gloves is next level only worn when working in sterile state
• Surgical attire covers you in gloves, cap, masks and eyewear.

Anesthesia

• Anesthesia means "lack of or no sensation", is needed to complete surgeries performed today
• With Anesthesia you can depress the body's reflexes, relaxs mussels, and change physiological factors
• The American Society of Anesthesiologist (ASA) assess the patient's risks before the operation.

Surgical Atire components

• Caps & masks are paper and never reused
• Gloves protect from bacteria but aren't substitute to washing
• Masks protect against coughs splatters. and always change when touch a patient
• Eye protection is also required from liquid threats
• Gowns are made of materials to protect cross contamination and exposure blood

Types of Anesthesia

• Anesthesia includes general, regional, local agent and monitored anesthesia care
• General Anesthesia is to "put to sleep" to reverse the conscious. Provides of all goals
• Involves; inhalation of gases, IV agents and relaxation to the mussels
• Some instances you wont need total relaxing or air support during the procedure

General Anesthesia - Volatile Agents

• gases includes ; isoflurane, sevoflurane, desflurane, and nitrous oxide.
• Gases helps achieve great effects but only known for the time it takes to see a effect

General Anesthesia - Intravenous Agents

• includes Barbiturates, Benzodiazepines, Opioids, Propofol, Ketamine, and Sedative-hypnotics
  • Barbiturates depresses the body's central system,
  • Benzodiazepines increases receptors GABA to help make patient numb. longer to take effect though
  • Opioids help bind muscles receptors to produce the same affect. May slow down breathing
  • Propofol works and wears off to quickly. Helps memory loss but not pain. Always pair it with analgesics
  • Ketamine gives you dissociated from you body but not asleep. Hallucinations can be common, its great for pain and sedative

General Anesthesia - Muscle relaxants

• Relax mussels happens using depolarizing and nondepolarizing agent's.
  • Succinylcholine helps block the the the joining sites so it can be relaxed. Adverse effects includes malignant hyperthermia (MH)
• Nondepolarizing agents help cause with muscles but not depolarizing it's effects.
  • Can be reversed only before protection is withdrawn. and may cause bradycardia

##Commonly Used Anesthetics

• A vast array of options include Propofol, Opioid Analgesics, Dexmedetomidine, Etomidate, Ketamine, and Diazepam

Commonly Used Anesthetics - Depolarizing Muscle Relaxants

• Help with airway and has a short window and works fast. May can cause malignant hyperthermia. Succinylcholine is a drug that helps

Commonly Used Anesthetics Nondepolarizing Muscle Relaxants

• With the usage of drugs such as Vecuronium, Cisatracurium and Rocuronium to help keep a patient relaxed,
  • Always ensure the patient well being.

Cholinergic Agent

Helps reverse the process of paralyzed agents with help of Neostigmine.

• May need either atropine or glycopyrrolate as well
• Anesthesia is sequenced using an sequence 1st induction 2nd placement of tube 3rd maintenance of tube 4ths emergence from patient wakingup/ 5th recovery. Anesthesia also have problems to watch that have effect patient's
• Complications such as Hypoxia, Dysfunction, Hypotension. Imbalances, Paralysis and problems inside

Malignant hyperthermia (MH)

• This is a state that is caused by exposure it's a genetics effects volatile's. That increases muscular contractions by an elevated intracellular.

• Is needed cooling and muscle contraction as well as cooling the patient. It should be near treated and diagnosed.

• It effects can be genetic but only in rare conditions

• Always warn patients when history of problems with anesthesia

Regional Anesthesia

• Blocks or numbs nerves or fiber of with blocks on the body such as blocks epidural Caudal and nerves

Spinal medication:

• Is medication is needed to do through canal of the spinal cord.

• Continuous spinal it needs the bed's flat after the help prevent the patient from headaches

• medication is injected into the epidural space of lumbar. to continuous effects

• Caudal is the medication inject to the epidural space

• a nerve blockers help the body can perform surgery

• Untoward effects, blood press can drop, spinal cord headaches and sezuires may happened due to meds

• Nerve problems/abscess are rare

Anesthetics:

Caused blockages that inhibits and causes motor problems to arise, and over usage/allergic problems to develop, itching and hives to arise

• amide are most local.
• Lidocaine needs to fast and needs to last 120/60 min, the most common

is Bupivacaine that lasts for 4-8 hrs that and slow and can cause postoperative Both can helps blood control in that procedure. esters:

• cocaine has a long effects for nasal it constricts the body
• care (MAC):

Gives patient a more relaxed state with more control. Some benefits include more response with less pain, and quick safe feeling. diazepam, midazolam, and narcotics, such as fentanyl and meperidine is used in conjunction with MAC Always be mindful around awake patients

Airway Management

protects or ensures the processs to breaths during a procedure, is helpful to make sure oxygen is ok The compromise complications are reflexive contractions, too much tube passes carina, perforated, Aspirations from other fluids includes facemask, or inserting it to the patients LMA: great for patient whom needs assistance with undergoing for brief surgeries and doesnt need any paralyzing.

tube: Helps when you are putting air in through carina to block aspirations You can give assistants to work that that needs assistance variations for ETT's is need can used in many areas

Patient positioning helps in the surgical time, patient safety is top. Also helps the surgical people. Patient is at risk so device needs to stop anything bad happening. Team needs to discuss the device and position needed as safety and comfort is the goal to patient and working conditions position: the body can either be in Prone, Lithotomy , Lateral, Supine. But is needed the right aid Rules has the patient to top is. Device helps to the top is is needed Body contact to to non padded as well. And slow movements. Check and baseline what is there

Surgical Positions - Supine

pressure points for the the is Occiput/ scuplar,. vertebrae. Olecrano,, Sacrum arms need to be less that 90 degrees. with no crossed ankles The team can use Trendelenburg, Reverse Trendelenburg, to help the patients as well help any problem is is see

Surgical Positions - Prone

pressure point are the cheeks eyes/ Toes use and pillow pads help protect from those pressures

• The team needs to check for the patient as it goes along as we can protect the patients

Surgical Positions - Lithotomy

Is needs that Hip Dislocations , back muscle as a result And any thing more than 2hours is is needed. The buttocks cannot hang off the end.

Patients factors/High risk

that geriatric patients that can be damaged due to pressure and moisture. As well any immature systems,

nursing list

helps to determine what is needed: such as assess , action and teaching. signed consent as things needs to get signed and read.

actions always needs help such as the surgical part. and the and equipment, and the ground. patient always safe Teaching the patient what there doing and ask. helps a lot. to help the operative state