DAY-2-Module-1-Perioperative-Nursing.pdf

JOMZ JULES GALVEZ, RN Intraoperative Care -Extends from the time the client is admitted to the OR, to the time of administration of anesthesia, surgical procedure is done, until...

JOMZ JULES GALVEZ, RN Intraoperative Care -Extends from the time the client is admitted to the OR, to the time of administration of anesthesia, surgical procedure is done, until the client is transferred to the RR/PACU. Intraoperative Care Principles of Sterile Technique 1. Only sterile items are used in the sterile field. 2. Sterile persons are gowned and gloved. 3. Gowns are sterile from front to waist level and front of sleeves. 4. Tables are sterile only at table level. 5. Sterile persons only touch sterile items or areas; unsterile persons touch only unsterile items or areas. 6. Edges of anything that encloses sterile contents are considered unsterile. 7. Sterile field is created as close as possible to time of use. 8. Sterile areas are continuously kept on view. 9. Sterile persons keep contact to sterile area to minimum. 10. Destruction of integrity o microbial barriers result in contamination. 11. Microorganisms must be kept to irreducible minimum. Intraoperative Care Duties and Responsibilities of a Circulating Nurse Has knowledge of surgical procedures, including anatomy and physiology. Assist in room preparation. Uses and monitors aseptic technique. Checks that needed equipment is available and in proper working order for surgery. Identifies/Assesses the client, Scans the pt chart for required data. Assist in transporting the patient to the Operating Room table. Assist in positioning the client and setting up monitoring devices as needed.  Stands by patient during anesthetic induction and emergence. Preps skin for incision; Monitors draping/ aseptic technique. Check / provides suctioning. Documents data on intraoperative record. Labels, records, sends specimen to the lab. Monitors/records fluid and blood losses. Counts sponges, needles, and instruments with the scrub nurse. Coordinates activities between OR and other departments. Assists in moving patient to the RR, Perform patient endorsement to RR NOD. Intraoperative Care Duties and Responsibilities of a Scrub Nurse Knowledge of surgical procedures including anatomy and physiology. Assists in room preparation. Performs Scrubbing, Gowning and Gloving. Assists other members (Surgeon) in Gowning and Gloving. Assist with draping. Uses and monitors aseptic technique. Passes instruments, sponges, and sutures to surgeons. Monitors amount of irrigation solution used. Counts sponges, needles, and instruments with the Circulating Nurse. The Surgical Team The Patient The Nurse (Scrub and Circulating) The Surgeon The Anesthesiologist or Anesthetist Surgical Technologist  The SURGEON performs the surgical procedure. Head the surgical team. The Registered Nurse First Assistant (RNFA) practice under the direct supervision of the surgeon. Provides exposure to the operative field, suturing, maintaining homeostasis.  The ANESTHESIOLOGIST Is a doctor responsible for administering anesthetics. Assess patient before the surgery, select the type of anesthesia to be used. Manages any technical problem related to the administration of anesthetic. Supervise the patient condition throughout the surgery. The Surgical Environment Stark and Cool appearance. Lies behind a double door, access is limited to authorized personnel. Suited in a location that is centered to all supporting services. Has special air filtration devices to screen out contaminating particles, dust, and pollutants. Has 3 zones: I. Unrestricted zone (street clothes allowed) II. Semi-restricted zone (scrubs and cap) III. Restricted zone (scrubs, cap, mask, and shoe cover) Intraoperative Care Arrival in the Operating Room 1. When the client arrives in the operating room, the operating room nurse will verify the identification bracelet with the client’s verbal response and will review the patients chart. 2. The operating room nurse will confirm the operative procedure and the operative site. 3. The client’s chart will be checked for completeness, reviewed for informed consent forms, History and PE, and allergic reaction information. 4. Physicians orders will be verified and implemented. 5. The IV line may be initiated at this time if prescribed. 6. The anesthesia team will administer the prescribed anesthesia. Types of Anesthesia Types of Anesthesia Regional Anesthesia Form of local Anesthesia Injected around nerves (E.g. Epidural, Spinal, local conduction block Epidural Anesthesia: ▪ Injection of local anesthetic agents into epidural space that surrounds the dura matter of the spinal cord. ▪ Differ from spinal anesthesia by site of injection and amount used. ▪ Advantage: Absence of headache. ▪ Disadvantage: Needs highly technique in administration. ▪ Injection of agent into epidural space. ▪ Does not enter CSF. ▪ Binds to nerve roots as they enter and exit the spinal cord. ▪ Patient can remain fully conscious. ▪ Decreased incidence of headache associated with spinal anesthesia. ▪ Observe closely for signs of autonomic nervous system (ANS) blockade: o Bradycardia o Hypotension o Nausea/ Vomiting Regional Anesthesia Spinal Anesthesia: ▪ Introduction of anesthetics into subarachnoid space at the Lumbar level (L4 and L5) ▪ Produce Anesthesia to lower abdomen, perineum, and lower extremities. ▪ Disadvantage: Nausea, Vomiting, Pain, Severe Headache ▪ Autonomic, Sensory, and motor blockade. ▪ May become hypotensive from vasodilation. Local Anesthesia Local Anesthesia: ▪ Insertion of anesthesia into the tissue at planned incision site. ▪ Advantage: simple, economical, minimal equipment is needed, ideal for short and superficial surgical procedure, undesirable effect of GA avoided. ▪ Disadvantage: High level of anxiety Intraoperative Care Potential Adverse effects of Surgery and Anesthesia Allergic reactions and drug toxicity or reactions. Cardiac Dysrhythmias CNS changes and oversedation or undersedation. Trauma: Laryngeal, oral, nerve, and skin, including burns. Hypotension Thrombosis  Intraoperative Complications Nausea and Vomiting Anaphylaxis Hypoxia and Respiratory complications Hypothermia Malignant Hyperthermia – is a rare inherited muscle disorder induced by anesthetic agent; it manifest 10-20 min after induction of anesthesia; it can occur in the first 24hrs.  Nursing Process for Patient during Surgery ▪ Dx Anxiety r/t expressed concerns due to surgery or OR environment. Risk for perioperative positioning r/t positioning in the OR. Risk for injury related to anesthesia and surgery. Disturbed Sensory perception r/t GA or sedation. ▪ Goal Reducing Anxiety Preventing positioning injuries Maintaining patient safety Avoiding complications ▪ Intervention Reducing anxiety Introducing self Address pt by name Verifying details and providing explanation Rationale: To help patient feel secure; Tell patient who will be in the OR, and how long the procedure may last; helps pt gain sense of control.  Preventing positioning injuries Place pt in comfortable position Expose the operative field adequately Respiratory should not be impeded by pressure Maintain pt safety Mild restrain may be needed during excitement stage Place arm board under the patient cannulated hand to facilitate IV infusion of fluid. Surgical Positions  Maintaining Patient Safety Identification of Patient and Correct informed consent Verification of Health record, Hx and PE Dx test results Assess for allergies Monitoring and modifying the physical environment Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient Verification an accessibility of blood ▪ Avoiding complications For N &V: place pt head at side, lowered the head, provide kidney basin, suction vomitus For anaphylaxis: assess pt v/s, administer medication For hypoxia: monitor pt oxygenation status, apply O2 as needed, monitor pulse oximeter reading For hypothermia: warm IV, remove and replace wet gown, warm pt gradually For Malignant hyperthermia: give pt O2, asses pt at risk Postoperative Care Admission to PACU Maintain airway Monitor vital signs Assess effects of anesthesia Provide comfort and pain relief Ends with follow-up evaluation in clinical setting or home.  Postoperative Care Goal: ❖to prevent complications, to promote healing of the surgical incision, and to return the client to a healthy state. Postoperative Care (IMMEDIATE) -The period 1 – 4 Hrs after surgery A. Respiratory System 1. Monitor vital signs 2. Monitor airway patency and adequate ventilation because prolonged mechanical ventilation during anesthesia affect postoperative lung function. 3. Remember that extubated clients who are lethargic may not be able to maintain airway. 4. Monitor for secretions; if the client is unable to clear the airway by coughing, suction the secretions from the client’s airway. 5. Observe for chest movement for symmetry and the use of accessory muscles. 6. Monitor oxygen administration if prescribed. 7. Encourage deep breathing and coughing exercises as soon as possible. 8. Note the rate, depth, and quality of respirations; the respiratory rate should be greater than 10 and less than 30 breaths per minute. 9. Assess breath sounds; stridor, wheezing or crowing can indicate partial obstruction, bronchospasm, or laryngospasm; crackles or rhonchi may indicate pulmonary edema. 10. Monitor for signs of atelectasis, pneumonia, or pulmonary embolism. B. Cardiovascular System 1. Assess the skin and check capillary refill. 2. Assess for peripheral edema. 3. Monitor for bleeding. 4. Assess pulse for rate and rhythm; a bounding pulse may indicate hypertension, fluid overload, or excitement. 5. Monitor for signs of hypertension and hypotension. 6. Monitor for cardiac dysrhythmias. 7. Assess for Homan’s sign, particularly in clients positioned in lithotomy position during surgery. C. Musculoskeletal System 1. Assess the client for movement of the extremities. 2. Review Physician’s orders regarding client positioning or restrictions. 3. Unless contraindicated, place client in a low Fowler’s position (30°) after surgery to increase the size of the thorax for lung expansion. 4. Avoid positioning the client in a supine position until pharyngeal reflexes have returned. 5. If the client is comatose or semicomatose, position on the side and keep an oral airway in place. D. Neurological System 1. Assess level of consciousness. 2. Frequent periodic attempts to awaken the client should continue until the client awakens. 3. Orient the client to environment. 4. Speak in a soft tone; filter out extraneous noises in the environment. 5. Maintain body temperature and prevent heat loss by providing the client with warm blankets and raising the room temperature as necessary. E. Temperature Control 1. Monitor temperature 2. Monitor for signs of hypothermia that may result from anesthesia, a cool operating room , or exposure of the skin and internal organs during surgery. 3. Apply warm blankets and continue oxygen as prescribed if the client is shivering. F. Integumentary System 1. Assess surgical site, drains, and wound dressings. 2. Monitor for and document any drainage or bleeding from the surgical site. 3. Assess the skin for redness, abrasions, or breakdown that may have resulted from surgical positioning. G. Fluid and Electrolyte balance 1. Monitor IV administration as prescribed. 2. Record intake and output. 3. Monitor for signs of hypocalcemia, hypoglycemia, and metabolic or respiratory acidosis or alkalosis. H. Gastrointestinal System 1. Monitor for nausea and vomiting. 2. Maintain patency of nasogastric tube if present. 3. Monitor for abdominal distention. 4. Monitor for return of bowel sounds. I. Renal System 1. Assess bladder for distention. 2. Monitor color, quantity, and quality of urine output if a Foley catheter is present. 3. Expect the client to avoid 6 to 8 hours after surgical procedure, depending on the type of anesthesia administered. J. Pain Management 1. Assess for pain. 2. Assess the type of anesthetic used and preoperative medication that the client received, and note whether the client received any pain medications in the post-anesthesia period. 3. Inquire about the type and location of pain. 4. Ask the client to rate the degree of pain on a scale of 1 to 10, with 10 being the most severe. 5. Monitor for objective data related to pain, such as facial expressions, body gestures, increased pulse rate, increased blood pressure, and increased respirations. 6. Inquire about the effectiveness of the last pain medication. 7. Administer pain medication as prescribed. 8. Ensure that a client with a client-controlled analgesia pump understands how to use it. 9. If a narcotic has been prescribed , during the initial administration, assess the client every 30 minutes for respiratory rate and pain relief. 10. Use noninvasive measures to relieve postoperative pain, including distraction, comfort measures, positioning, backrubs, and providing a quite and restful environment. 11. Document effectiveness of pain medication and noninvasive pain relief measures.