Nursing Perioperative Part 2: Intraoperative role of Nurse

Surgical Environments

• Patients arrive from the Short Stay Unit (SDS) or from a unit within the hospital
• The surgical environment is unique by being geographically, environmentally, and bacteriologically restricted

Surgical Team Members

• The circulating nurse is always a Registered Nurse (RN) and provides care based on the nursing process
• Circulating nurses direct and coordinate activities related to patient care/support
• Circulating nurses maintain a safe and comfortable environment as well as communication

Other Surgical Team Members

• The surgical team includes a Licensed Practical Nurse
• The surgical team includes a Surgical Technician
• The surgical team includes the Anesthesiologist
• The surgical team includes a CRNA (Advanced Practice Nurse) or Anesthesia Assistants under direct supervision of anesthesiologist

Intraoperative Nurse Responsibilities

• Psychosocial support and physical assessment review should be accomplished
• Chart assessment and proper admission to the surgical suite should also be achieved
• Maintaining patient safety is critical
• Surgical Care Improvement Project (SCIP) measures should be followed
• Universal protocols should be followed

Surgical Quality Indicators

• SCIP is the Surgical Care Improvement Project
• Hospitals must adhere to SCIP requirements mandated by the Joint Commission
• SCIP actions are required to be completed within the stated perioperative time frame
• Further handout information is available on Blackboard

Universal Protocol

• Universal Protocol is required by The Joint Commission
• Universal Protocol is designed to ensure correct: patient identity, scheduled procedure, surgical site
• Universal Protocol includes the pre-op verification process
• Universal Protocol includes marking the operative site
• Universal Protocol includes a "Time Out" which is to be done immediately before starting the procedure in the OR

Nursing Management for the Intra-op Nurse

• Maintain aseptic/sterile technique
• Assist with patient transfer/positioning
• Transfer/positioning usually occurs after induction
• Protect bony prominences, correct skeletal alignment, prevent occlusion of arteries/veins, and prevent compression of nerve tissue
• Provide for privacy/modesty
• Provide for patient safety

Anesthesia

• The type of anesthetic and technique is decided by anesthesiologist
• Collaboration with surgeon and patient takes into consideration patient's medical co-morbidities
• Types: General, regional, local and monitored anesthesia care (MAC).

Anesthesia: Balanced Anesthesia

• Balanced anesthesia uses more than one anesthetic agent of differing drug classes, to produce the effects needed
• Desired outcomes include: physiologic homeostasis, analgesia, amnesia, and adequate muscle relaxation

Anesthesia: General Anesthesia

• Effects include: loss of sensation and consciousness, skeletal muscle relaxation, analgesia, and elimination of somatic, autonomic, and endocrine responses

Anesthesia: Phases of General Anesthesia

• Pre-Induction begins with pre-op meds and initiation of monitoring devices such as IV, EKG, and special tubes
• Induction is the initiation of medications to cause unconsciousness with airway secured
• Maintenance is the time during which the surgical procedure is performed
• Emergence is the time period when the surgical procedure has been completed

Anesthesia: General Anesthesia - Induction

• Induction is a time when the patient could have problems and requires maximum attention
• Potential problems include: coughing, retching, vomiting, and laryngospasm
• Stimulation should be avoided, including movement and noise

Anesthesia: Role of the RN related to Anesthesia

• Pre-Induction: complete pre-op assessment, check and confirm consent form, and initiate "Time-Out" for patient
• Induction: assist with application of monitoring devices, assist with airway management
• Maintenance: maintain patient safety, positioning
• Emergence: assist in placement of dressing, maintain patient safety as reflexes/movements return, provide psychological support, and prepare for PACU

Anesthesia: General Anesthesia - Intravenous

• Virtually all adult general anesthesia begins with IV induction
• IV induction results in a pleasant sleep with rapid onset of action and is the beginning of anesthesia
• A single dose lasts only a few minutes; just long enough for airway to be established and for inhalation agent to be started

Anesthesia: General Anesthesia - Inhalation Agents

• Inhalation Agents are the "cornerstone" of general anesthesia
• Inhalation Agents are usually administered through an endotracheal tube (ETT) or laryngeal mask airway (LMA)

Anesthesia: General Anesthesia - Inhalation Agents

• Volatile Liquids are administered through a special vaporizer
• Volatile Liquids are mixed with oxygen as a carrier gas
• Volatile Liquids all are: vasodilators, bronchodilators, myocardial depressants, and muscle relaxants
• Gases are rarely used alone and are added to balanced anesthesia
• Gases have a high analgesic effect
• Gases must be given with oxygen to prevent hypoxemia

Anesthesia related to Intubation and General Anesthesia

• Potential Complications include: trauma to teeth, lips, vocal cords or trachea
• Additional potential complications: sore throat or hoarseness, irritation from tube/irritation from inhalation agents, laryngospasm or bronchospasm
• More potential complications: Increased secretions, and gases may irritate respiratory tract

Anesthesia: Adjuncts to General Anesthesia

• Adjuncts are given IN ADDITION to inhalation anesthetic, as part of balanced anesthesia
• Adjuncts include: Opioids - narcotics, Benzodiazepines – sedative/hypnotics, Neuromuscular Blocking Agents – muscle relaxants, and Anti-emetics – N/V

Anesthesia: Local Anesthesia

• Action: Interrupts nerve impulses and blocks motor(movement) and sensory(feeling) impulses in the area
• Use: Procedure can be performed without loss of consciousness or sedation
• Methods of administering topical, local infiltration, nebulized, and ophthalmic

Anesthesia: Regional Anesthesia

• Regional Injection: Injection of local anesthesia around or near nerve groups
• Types of regional anesthesia include: Regional (peripheral) nerve block, IV Regional block (Bier's block), Spinal block (CSF), Epidural

Anesthesia: Spinal vs Epidural Administration

• Spinal vs Epidural administration refer to the location of anesthetic administration in the spine in relation to the spinal cord, vertebra, nerve roots, and epidural space

Anesthesia: Local/Regional Anesthesia

• Potential Side Effects/Adverse Reactions
• Spinal: Headache due to CSF leaking at the site of injection related to the needle gauge size
• Local can eventually be absorbed into the bloodstream causing: palpitations, tachycardia, tremor, pallor, diaphoresis

Anesthesia: Monitored Anesthesia Care (MAC)

• "Twilight Sleep" leads to a depressed LOC; following IV administration of: Benzodiazepam, usually midazolam (Versed) or Opioids
• Retains ability to: Maintain own airway, Respond appropriately to verbal commands
• Relieves anxiety, provides analgesia/amnesia

Malignant Hyperthermia

• Malignant Hyperthermia (MH) is a rare metabolic disease which is dominant inherited
• MH has a progressive rise in body temperature, six degrees Celsius/hour, and is often fatal
• MH symptoms include hyperthermia with rigidity of skeletal muscles
• MH occurs in certain people when exposed to certain anesthetic agents, such as Succinylcholine
• Tachycardia, tachypnea, hypercarbia, ventricular ectopy, and hyperthermia
• Treatment: Dantrolene (Dantrium) – skeletal muscle relaxant
• Symptomatic support: Cooling blankets, Cold IV fluids

Sentinel Event

• Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury
• The event signals need for immediate investigation and response which will improve patient care
• Reporting the Sentinel Event is required
• Reporting focuses the organization on the event and facilitates change via an action plan

Sentinel Event: Top Ten Frequently Reviewed

• The top ten list contains event types that have been the most reviewed.