NUPC-113-Module-I.pdf

MODULE I PERIOPERATIVE NURSING CARE Lesson 1 Preoperative Care Lesson 2 Intraoperative Care Lesson 3 Postoperative Care Lesson 4 Surgical Instruments Prepared by...

MODULE I PERIOPERATIVE NURSING CARE Lesson 1 Preoperative Care Lesson 2 Intraoperative Care Lesson 3 Postoperative Care Lesson 4 Surgical Instruments Prepared by: JIMA J. MAMUNGAY First Semester, SY 2022-2023 Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  2 TABLE OF CONTENTS 3 Introduction 105Module Summary 3 Learning Outcomes 106Summative Test 3 Module Organizer 110References 4 Directions 111Appendix 6 Lesson 1 Preoperative Nursing Care 5 Pretest 9 Nursing Assessment 14 Nursing Diagnosis 14 Planning and Implementation 25 Consideration for Older Adults 28 Evaluation 31 Lesson 2 Intraoperative Nursing Care 30 Pretest 47 Nursing Assessment 48 Nursing Diagnosis 49 Planning and Implementation 56 Evaluation 59 Lesson 3 Postoperative Nursing Care 58 Pretest 62 Nursing Assessment 68 Nursing Diagnosis 69 Planning and Implementation 75 Evaluation 78 Lesson 4 Surgical Instruments 77 Pretest Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  3 MODULE I PERIOPERATIVE NURSING CARE INTRODUCTION This module introduces Perioperative Nursing Care as part of your course Care of Client with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic. Perioperative Nursing Care means the delivery of care to patients during the preoperative, intraoperative and postoperative period of surgery. This module will help you deliver appropriate and safe care and interventions to patients who will undergo surgical procedures that will hone you to become good and responsible nurses in the future. LEARNING OUTCOMES After studying the module, you should be able to: 1. differentiate the common purposes and settings of surgery. 2. utilize the nursing process in the care of individuals and families who will undergo surgical procedures during the perioperative period. 3. ensure a well-organized and accurate documentation system of patient perioperatively. 4. observe bioethical concepts and principles, core values and nursing standards in the care of clients during the perioperative period. 5. collaborate appropriately with patient/s, their families, and the health care team to promote SAFETY of patients before (preoperative), during (intraoperative), and after (postoperative) surgery to ensure patient-centered care. 6. apply basic principles of aseptic technique used in the operating room to promote safety relative to patients, equipment, and anesthesia. 7. identify the use and function of each type of surgical instrument. MODULE ORGANIZER Hi! My name is Jima Jose Mamungay. I will be your Instructor for this course. In case you encounter difficulty, discuss this with me during the scheduled face-to-face Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  4 meeting at the CCHAMS Faculty Office or virtual meeting. If not, contact me to this following contact details: [email protected] Jima Querrer Jose Mamungay 09178417848 MODULE GUIDE There are four lessons in this module. Before you begin each lesson, you will take the pretest first to determine if you are sufficiently prepared to begin. Read each lesson carefully. Lesson 1 to 3 starts with the brief overview of the topic and followed by steps in the nursing process while lesson 4 is about surgical instruments. After reading each lesson, you are required to answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully because they are graded and submit your output to my email given to you. Rubrics will be used to evaluate your outputs that are seen in the appendix section of this module. As you go along, there are important aspects of care that are highlighted. These aspects include the following: 1. NURSING SAFETY PRIORITY Boxes which highlights important information you can use to avoid patient harm. These are further categorized as Action Alert and Critical Rescue. 2. QSEN or Quality and Safety Education for Nurses reflect your role as a nurse in the health care system that improves quality and safety nursing interventions/actions. Moreover, these boxes reflect both competencies and quality measures that will help you become effective, safe, and efficient nurse who renders patient-centered care across settings. Good luck and happy reading!!! Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  5 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Preoperative Nursing Care. Write your answer in a piece of paper. Good luck. Be honest to yourself. I. Identification 1. It is the art and science of treating diseases, injuries and deformities using operation and instrumentation. It involves the interaction among the patient, surgeon, anesthesia care provider (ACP), nurse, and other health care team members as needed. 2. Give at least two roles of nurses preoperatively. 3. This kind of urgency of operation is described as planned for correction of a nonacute problem of a patient. 4. It requires prompt intervention and may be life threatening if treatment is delayed more then 24 to 48 hours. 5. It requires immediate intervention because of life-threatening consequences. 6. Give at least 5 purposes of operation. II. Give the meaning and one example of each suffix. Suffix Meaning Example -ectomy -lysis -orrhaphy -oscopy -ostomy -otomy -plasty “THREE LIFE RULES 1. If you don’t go after what you want, you’ll never have it. 2. If you don’t ask, the answer will always be no. 3. If you don’t step forward, you will always be in the same place.” -Unknown Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  6 Lesson 1 Preoperative Nursing Care Overview SURGERY It is an important It involves the role of nurses to interaction among The preoperative The art and prepare patients the patient, period begins science of treating prior to surgeon, when the patient diseases, injuries operations. Your anesthesia care is scheduled for and deformities primary roles as a provider (ACP), surgery and ends using operation nurse are nurse, and other at the time of and educator, patient health care team transfer to the instrumentation. advocate and members as surgical suite. promoter of needed. health. INPATIENT OUTPATIENT and AMBULATORY a patient who is admitted to a patient who goes to the a hospital the day before or surgical area the day of the the day of surgery and surgery and returns home on the requires hospitalization same day (same-day surgery or after surgery. SDS). Surgery may be performed for any of the following: o Purposes o Urgency of surgery o Risk of surgery o Extent of surgery Table 1 explains the categories and gives examples of surgical procedures. Meanwhile, Table 2 shows specific suffixes that are commonly used in combination with a body part or organ in naming surgical procedures. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  7 Table 1. Selected Categories of Surgical Procedures Category Description Condition or Surgical Procedure Purpose/Reasons for Surgery Diagnostics Performed to determine the Breast biopsy origin and cause of a disorder Exploratory laparotomy or the cell type for cancer. Arthroscopy Determination of the presence Lymph node biopsy and extent of a pathologic Bronchoscopy condition. Curative Performed to resolve a health Cholecystectomy problem by repairing or Appendectomy removing the cause. Hysterectomy Elimination or repair of a pathologic condition. Transplant Replacing malfunctioning Kidney/Heart/Liver transplant structures. Restorative Performed to improve a Total knee replacement patient’s functional ability. Finger reimplantation Palliative Performed to relieve Colostomy to bypass an symptoms of a disease process inoperable bowel obstruction but does not cure. Nerve root resection Alleviation of symptoms Tumor debulking without cure. Ileostomy Rhizotomy Cosmetic Performed primarily to alter or Liposuction Improvement enhance personal appearance Revision of scars Rhinoplasty Blepharoplasty Breast reconstruction after a mastectomy Exploration Surgical examination to Laparotomy determine the nature or extent of a disease. With the advent of advanced diagnostic tests, exploration is less common because problems can be identified earlier and easier. Urgency of Surgery Elective Planned for correction of a Cataract removal nonacute problem. Hernia repair Total joint replacement Hemorrhoidectomy Urgent Requires prompt intervention; Intestinal/Bladder obstruction may be life threatening if Kidney or ureteral stones treatment is delayed more Bone fracture than 24-48 hours. Eye injury Acute cholecystitis Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  8 Emergent Requires immediate Gunshot or stab wound intervention because of life- Severe bleeding threatening consequences. Abdominal aortic aneurysm Compound fracture Appendectomy Surgical Approach Simple Only the most overtly affected Simple/ Partial mastectomy areas involved in the surgery. Minimally Surgery performed in a body Arthroscopy invasive cavity or body area through Tubal ligation surgery (MIS) one or more endoscopes. Hysterectomy Can correct problems, remove Lung lobectomy organs, take tissue for biopsy, Coronary artery bypass re-route blood vessels and Cholecystectomy drainage systems. It is a fast-growing and ever- changing type of surgery. Radical Extensive surgery beyond the Radical prostatectomy area obviously involved Radical hysterectomy It is directed at finding a root cause. Table 2. Suffixes Describing Surgical Procedures Suffix Meaning Example -ectomy Excision or removal of Appendectomy -lysis Destruction of Electrolysis -orrhaphy Repair or suture of Herniorrhaphy -oscopy Looking into Endoscopy -ostomy Creation of opening into Colostomy -otomy Cutting into or incision of Tracheotomy -plasty Repair or reconstruction of Mammoplasty -centesis Puncture a cavity to remove fluid Amniocentesis -opexy Surgical suspension or fixation Hysteropexy -otripsy Crushing or destroying Lithotripsy -desis Binding or fusing Pleurodesis Preoperative interview is one of the utmost essential nursing actions done by the nurse who works in the physician’s office, the ambulatory surgery center, or the hospital preoperative area. o The place of the interview and the time before surgical procedure dictate the depth and completeness of the interview. o Important findings must be documented and communicated to others to maintain continuity of care. o The preoperative interview can occur in advance or on the day of surgery. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  9 o Ensure that the patient’s consent form for surgery has been signed and witnessed and that the appropriate laboratory and diagnostic tests have been ordered or completed. o The interview also provides the patient and the caregiver an opportunity to ask questions about surgery, anesthesia, and postoperative care. o Often patients ask about taking their routine medications, such as insulin, anticoagulants, or cardiac medications, and if they will experience pain. By being aware of the patient’s and caregiver’s needs, you can provide the information and support needed during the perioperative period. Primary Purposes of PREOPERATIVE INTERVIEW obtain the patient health's information. provide and clarify information about the planned surgery. assess the patient's emotional state and readiness for surgery, including his or her expectations about the surgical outcomes. Nursing Assessment of Preoperative Patient Obtain a focused assessment. Ensure that the patient's confidentiality is protected. Privacy increases the patient's comfort with the interview process and may help reduce the stress associated with the surgery and anesthesia. Use of Patient’s Age tobacco, psychosocial alcohol, or status illicit substances Type of Current surgery drugs planned Family history ESSENTIAL Complementary or alternative DATA practices ELEMENTS General Medical health history Allergies, including Prior sensitivity surgical to latex Autologous procedures products or directed Prior blood experiences donations Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  10 Chart 1 shows the psychosocial assessment of preoperative patient. Assess the patient for problems that increase the risk for complications during and after surgery. Table 3 presents the factors that increase the Risk for Surgical Complications. Take and record vital signs and report: 1. Hypotension or hypertension 2. Heart rate less than 60 or more than 120 beats/min 3. Irregular heart rate 4. Chest pain 5. Shortness of breath or dyspnea 6. Tachypnea 7. Pulse oximetry reading of less than 94% Chart 1. Psychosocial Assessment Of Preoperative Patient Situational Changes Identify support systems, including family, other caregivers, group and institutional structures, and religious and spiritual groups. Define current degree of personal control, decision making, and independence. Consider the impact of surgery and hospitalization and the possible effects on lifestyle. Determine the presence of hope and anticipation of positive results. Concerns With the Unknown  Identify specific areas and degree of anxiety and fears related to the surgery (e.g., pain).  Identify expectations of surgery, changes in current health status, effects on daily living, and sexual activity (if appropriate). Concerns With Body Image  Identify current roles or relationships and view of self.  Determine perceived or potential changes in roles or relationships and their impact on body image. Past Experiences  Review previous surgical experiences, hospitalizations, and treatments.  Determine responses to those experiences (positive and negative).  Identify current perceptions of surgical procedure in relation to the above and information from others (e.g., a friend’s view of a personal surgical experience). Knowledge Deficit  Identify the amount and type of preoperative information the patient wants.  Assess understanding of the surgical procedure, including preparation, care, interventions, preoperative activities, restrictions, and expected outcomes.  Identify the accuracy of information the patient has received from others, including health care team, family, friends, and the media Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  11 Table 3. Factors that increase the Risk for Surgical Complications. Age Older than 65 years Medications Antihypertensives Tricyclic antidepressants Anticoagulants Nonsteroidal anti-inflammatory drugs (NSAIDs) Immunosuppressives Medical History Decreased immunity Diabetes Pulmonary disease Cardiac disease Hemodynamic instability Multi-system disease Coagulation defect or disorder Anemia Dehydration Infection Hypertension Hypotension Any chronic disease Health History Malnutrition or obesity Drug, tobacco, alcohol, or illicit substance use or abuse Altered coping ability Herbal use Family History Malignant hyperthermia Cancer Bleeding disorder Anesthesia reactions or complications Prior Surgical Less-than-optimal emotional reaction Experiences Anesthesia reactions or complications Postoperative complications Assess for and report any signs or symptoms of infection, including: 1. Fever 2. Purulent sputum 3. Dysuria or cloudy, foul-smelling urine 4. Red, swollen, draining wound or vascular access site 5. Increased white blood cell count Assess for and report factors that could contraindicate surgery, including: 1. Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT). 2. Abnormal electrolytes, particularly hypokalemia or hyperkalemia Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  12 3. Patient report of possible pregnancy or positive pregnancy test Assess for and report clinical conditions that may need to be evaluated by a provider before proceeding with the surgical plans, including: 1. Change in mental status 2. Vomiting 3. Rash 4. Recent administration of an anticoagulant drug 5. Family or personal history of malignant hyperthermia with anesthesia Use a standardized list to ensure the following items are available before surgery starts: 1. History and physical 2. Signed, dated, and witnessed procedure consent form 3. Nursing assessment 4. Preanesthesia assessment 5. Labeled diagnostic and radiology test results. Two common but not required tests are chest x-ray and electrocardiogram (ECG). Tests specific to the condition or surgical procedure (e.g., CT scan, MRI scans, abdominal films, or orthopedic films) should also be noted. See table 4 for the list of common preoperative laboratory and diagnostic tests. Table 4. Common Preoperative Laboratory and Diagnostic Tests. Test Assessment ABGs, pulse oximetry Respiratory and metabolic function, oxygenation status Blood glucose Metabolic status, diabetes mellitus Blood urea nitrogen, Renal function creatinine Chest x-ray Pulmonary disorders, cardiac enlargement, heart failure Complete blood count: Anemia, immune status, infection RBCs, Hgb, Hct, WBCs, WBC differential Electrocardiogram Cardiac disease, dysrhythmias Electrolytes Metabolic status, renal function, diuretic side effects hCG Pregnancy status Liver function tests Liver status PT, PTT, INR, platelet count Coagulation status Serum albumin Nutritional status Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  13 Type and crossmatch Blood available for replacement (elective surgery patients may have own blood available) Urinalysis Renal status, hydration, urinary tract infection Pulmonary function studies Pulmonary status 6. Any required blood products, implants, devices, and/or special equipment for the procedure 7. Figure 1 presents a sample of Preoperative Checklist used to ensure that all preoperative preparations have been completed before the patient is given any sedating medications. But this preoperative checklist varies between institutions or organizations. Figure 1. Sample of Preoperative Checklist Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  14 Nursing Diagnosis Anxiety related to surgical experience and the outcome of surgery. Knowledge Deficit of preoperative procedures and protocols and post-operative expectations. Fear related to perceived threat of the surgical procedure and separation from support system. Planning and Implementation Explore the patient's level of knowledge and understanding of the planned surgery by having the patient explain in his or her own words the purpose and expected results. Ensure informed consent is obtained from the patient (or legal designee) by the surgeon before sedation is given and before surgery is performed. Consent implies that the patient has sufficient information to understand: 1. The nature of and reason for surgery 2. Who will perform the surgery and whether others will be present during the procedure 3. All available options and the risks associated with each option 4. The risks associated with the surgical procedure and its potential outcomes 5. The risks associated with the use of anesthesia CONSENT FOR SURGERY The patient must VOLUNTARILY SIGN an informed consent form in the presence of a witness before nonemergency surgery can be legally performed. INFORMED CONSENT is an active, shared decision-making process between the health care provider and the recipient of care. Three conditions must be met for consent to be valid.  There must be adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the risks and Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  15 consequences of the proposed treatment; the probability of a successful outcome; the availability, benefits, and risks of alternative treatments; and the prognosis if treatment is not instituted.  The patient must demonstrate CLEAR UNDERSTANDING OF THE INFORMATION being provided before receiving sedating preoperative medications.  The recipient of care must give consent VOLUNTARILY. The patient must NOT be persuaded or coerced in any way by anyone to undergo the procedure. The SURGEON is ultimately responsible for obtaining the patient’s consent for surgical treatment. Nurses may be responsible for witnessing the patient’s signature on the consent form. At this time, nurses can be a patient advocate, verifying that the patient (or caregiver) understands the information presented in the consent form and the implications of consent, and that consent for surgery is truly voluntary. If the patient is unclear about the surgical plans, contact the surgeon about the patient’s need for additional information. The patient should also be aware that consent, even when signed, can be withdrawn at any time. If the patient is a minor, unconscious, or mentally incompetent to sign the permit, a legally appointed representative or responsible family member may give written permission. An emancipated minor is one who is younger than the legal age of consent but is recognized as having the legal capacity to provide consent. A true medical emergency may override the need to obtain consent. When immediate medical treatment is needed to preserve life or to prevent serious impairment to life or limb and the patient is incapable of giving consent, the next of kin may give consent. If reaching the next of kin is not possible, the physician may begin treatment without written consent. A note is written in the chart documenting the medical necessity of the procedure. In the case of an emergency where consent cannot be obtained, the perioperative nurse usually needs to complete an event report because it is an occurrence that is inconsistent with routine facility practices. ACTION ALERT NURSING SAFETY PRIORITY If you believe that the patient has not been adequately informed, contact the surgeon and request that he or she see the patient for further clarification. Document this request in the medical record. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  16 ETHICAL/LEGAL DILEMMAS Informed Consent Situation J.S., a 72-year-old woman, is waiting in the preoperative holding area. You are discussing her impending surgery when you realize that this competent adult does not fully understand her surgery and was not informed of the alternatives to this surgery. Although she has previously signed a consent form, your assessment is that she was not fully informed about her treatment options or does not recall them. Ethical/Legal Points for Consideration Informed consent requires that patients have complete information about the proposed treatment, as well as alternative treatments, risks and benefits of each treatment option, and possible consequences of the surgical procedure. The person (usually the surgeon) performing the procedure usually has this responsibility. An opportunity to have questions answered about the various treatment options and their possible outcomes is also an important element of informed consent. A patient can revoke the consent at any time, even at the very last minute. It is essential that you report any circumstance that suggests that the patient does not understand the information or is revoking the informed consent to the person who obtained the consent. In most states, the registered nurse’s legal role is to witness the signing of the document. This means that as a nurse, you attest to the fact that the patient’s signature was valid. A competent adult has the right to refuse treatment for any reason, even when refusal might lead to death. Routine preoperative care includes: 1. Determining the existence and nature of the patient's advance directives. 2. Implementing dietary restrictions a. Recommendations include NPO status (no eating or drinking), typically for 6 or more hours for easily digested solid food and 2 hours for clear liquids. b. Failure to adhere to NPO status can result in cancellation of surgery or increase the risk for aspiration during or after surgery. 3. Administering regularly scheduled drugs a. Many oral drugs are held the morning before surgery or given IV. b. Others, especially for cardiac disease, respiratory disease, seizures, and hypertension, are usually allowed before surgery with a sip of water. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  17 4. Ensuring intestinal preparation a. Before abdominal, bowel, or intestinal surgery, a simple enema, "enemas until clear," or mild or potent laxatives (polyethylene glycol electrolyte solution [GOLYTELY) is an example of a potent laxative) may be prescribed to empty the large intestine to reduce the potential for contamination of the surgical field. b. Antibiotics may be administered immediately before abdominal surgery to reduce bacterial load in the gastro intestinal tract. 5. Performing skin preparation a. Confirm or assist the patient in the use of an antiseptic solution while showering and removal of oil and skin debris. This intervention reduces the number of organisms on the skin and the potential for a site infection. See figure 2 for the skin preparation of common surgical sites. b. Remove hair at the surgical site with clippers. 6. Preparing the patient for tubes, drains, and vascular access a. Describe the purpose and placement of each device. b. Show the devices to the patient and family. c. Reassure the patient that these are temporary and that efforts will be made to reduce discomfort. d. Common devices include: (1) Foley catheter (2) Nasogastric (NG) tube (3)Drains (e.g., Penrose, Jackson-Pratt, Hemovac) (4) Vascular access Foley Catheter Nasogastric Tube Vascular Access: Intrajugular Vein Central Line Peripherally Inserted Central Line Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  18 Penrose Drain Jackson Pratt Drain Hemovac Drain T-Tube Drain 7. Teaching about postoperative interventions to prevent respiratory complications a. Deep diaphragmatic and expansion breathing b. Incentive spirometry c. Coughing and splinting d. Turning and positioning Figure 2. Skin Preparation of common surgical sites. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  19 Teaching deep-breathing exercises, incentive spirometry, coughing and Splinting These exercises will speed your patient’s recovery and reduce his risk of respiratory complications DEEP-BREATHING EXERCISES Advise the patient that performing deep-breathing exercises several times per hour helps keep lungs fully expanded. To deep-breathe correctly, he must use his diaphragm and abdominal muscles, not just his chest muscles. Tell the patient to practice deep-breathing exercises two or three times per day before surgery, as follows: Have him lie on his back in a comfortable position with one hand placed on his chest and the other over his upper abdomen (as shown at right). Instruct him to relax and bend his legs slightly. Instruct him to exhale normally. He should then close his mouth and inhale deeply through his nose, concentrating on feeling his abdomen rise. His chest shouldn’t expand. Have him hold his breath and slowly count to five. Next, have the patient purse his lips as though about to whistle, then exhale completely through his mouth, without letting his cheeks puff out. His ribs should sink downward and inward. After resting several seconds, the patient should repeat the exercise five to ten times. He should also do this exercise while lying on his side, sitting, standing, or while turning in bed. INCENTIVE SPIROMETRY Incentive spirometry is another way to encourage the patient to take deep breaths. Its purposes are to promote complete lung expansion and prevent pulmonary problems. Various types of incentive spirometers are available; Figure 3 shows a patient using one type. With all types, the patient must be able to seal the lips tightly around the mouthpiece, inhale spontaneously, and hold his or her breath for 3 to 5 seconds for effective lung Figure 3. Patient using an expansion. Goals (e.g., attaining specific incentive spirometer volumes) can be set according to the patient's ability and the type of incentive spirometer. Seeing a ball move up a Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  20 column or a bellows expanding reinforces and motivates the patient to continue performance. COUGHING EXERCISES Patients who risk developing excess secretions should practice coughing exercises before surgery. However, patients about to undergo ear or eye surgery or repair of hiatal or large abdominal hernias won’t need to practice coughing. Also, patients undergoing neurosurgery shouldn’t cough postoperatively because intracranial pressure will rise. Tell the patient to practice coughing exercises, as follows: If the patient’s condition permits, instruct him to sit on the edge of his bed (as shown at right). Provide a stool if his feet don’t touch the floor. Tell him to bend his legs and lean slightly forward. If the patient is scheduled for chest or abdominal surgery, teach him how to splint his incision before he coughs. Instruct the patient to take a slow, deep breath; he should breathe in through his nose and concentrate on fully expanding his chest. Then he should breathe out through his mouth and concentrate on feeling his chest sink downward and inward. Then he should take a second breath in the same manner. Next, tell him to take a third deep breath and hold it. He should then cough two or three times in a row (once isn’t enough). This will clear his breathing passages. Encourage him to concentrate on feeling his diaphragm force out all the air in his chest. Then he should take three to five normal breaths, exhale slowly, and relax. Have the patient repeat this exercise at least once. After surgery, he’ll need to perform it at least every 2 hours to help keep his lungs free from secretions. Re-assure the patient that his stitches are very strong and won’t split during coughing. SPLINTING OF THE SURGICAL INCISION Splinting supports the incision and surrounding tissues and reduces pain during coughing. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over your surgical incision and hold the item firmly in place (as shown in the right). Take three slow, deep breaths to stimulate your cough reflex. Inhale through your nose and exhale through your mouth. On your third deep breath, cough to clear secretions from your lungs while firmly holding the pillow, towel, or folded blanket against your incision. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  21 8. Teaching about identification and prevention of cardiovascular complications a. Assess for venous thromboembolism (VTE) as swelling in one leg and/or presence of calf pain that worsens with ambulation. b. Use antiembolism stockings (TEDs or Jobst stockings), elastic (Ace) wraps, or pneumatic compression (see figure 4) devices to prevent superficial venous stasis. Figure 4. External pneumatic compression device used to promote venous return and prevent deep vein thrombosis (DVT). c. Use leg exercises and early ambulation to promote venous return. See table 5 for the list of Postoperative Leg Exercises. Table 5. Postoperative Leg Exercises Exercise No. 1 (see Figure 5) 1. Lie in bed with the head of your bed elevated to about 45 degrees. 2. Beginning with your right leg, bend your knee, raise your foot off the bed, and hold this position for a few seconds. 3. Extend your leg by straightening your knee and lower the leg to the bed. Figure 5. Postoperative 4. Repeat this sequence four more times Leg Exercise 1 with your right leg; then perform this same exercise five times with your left leg. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  22 Exercise No. 2 (see Figure 6) 1. Beginning with your right leg, point your toes toward the bottom of the bed. 2. With the same leg, point your toes up toward your face. 3. Repeat this exercise several times with your right leg; then perform this same Figure 6. Postoperative exercise with your left leg. Leg Exercise No. 2 Exercise No. 3 (see Figure 7) 1. Beginning with your right leg, make circles with your ankle, first to the left and then to the right. 2. Repeat this exercise several times with your right leg; then perform this same Figure 7. Postoperative exercise with your left leg. Leg Exercise No.3 Exercise No. 4 (see Figure 8) 1. Beginning with your right leg, bend your knee and push the ball of your foot into the bed or floor until you feel your calf and thigh muscles contracting. 2. Repeat this exercise several times with your right leg; then perform this same exercise with your left leg. Figure 8. Postoperative Leg Exercise No. 4 9. Minimizing anxiety a. Assess the patient's knowledge about the surgical experience. b. Allow ample time for questions. c. Respond to questions accurately or facilitate communication with the knowledgeable care provider. d. Incorporate family or supportive persons in communications. e. Provide prescribed antianxiety drugs. f. Promote rest and relaxation. g. Provide opportunity for distraction. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  23 Final Preoperative Preparation Review the preoperative chart for: 1. Completion of surgical informed consent form and any other special consent forms: a. Patient's signature b. Date c. Witnesses' signatures 2. Confirmation that the scheduled procedure is what is listed on the consent form. CRITICAL RESCUE NURSING SAFETY PRIORITY At a minimum, the patient's identity, correct side and site, correct patient position, and agreement on the proposed procedure must be verified by all members of the surgical team. 3. Documentation of allergies. 4. Accurate height and weight. 5. Documentation of the results of all laboratory, radiographic, and diagnostic tests in the chart. 6. Presence of autologous blood donor or directed blood donations slips (if appropriate). 7. Documentation of current vital signs, within 1 to 2 hours of the scheduled surgery time. 8. Documentation of any significant physical or psychosocial observations. ACTION ALERT NURSING SAFETY PRIORITY Ask about a history of joint replacement, and document the exact location of any prostheses. Communicate this information to operating room personnel to ensure that electrocautery pads, which could cause an electrical burn, are not placed on or near the area of the prosthesis. Other areas to avoid electrocautery pad placement include on or near bony prominences, scar tissue, hair, tattoos, weight- bearing surfaces, pressure points, or metal piercings. 9. Communication of special needs, concerns, and instructions to the surgical team such as: Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  24 a. Advance directives b. No use of blood products c. Presence of autologous blood products d. Communication difficulties (e.g., visually impaired, hearing impaired, does not speak the main language of the institution) Review patient preparation: 1. Appropriate clothing removal 2. Application of prescribed antiembolism stockings or pneumatic compression devices 3. Storage of valuables 4. Visible patient identification (e.g., identification band) 5. Removal and safekeeping of dentures, dental prostheses (e.g., bridges, retainers), jewelry (including body piercing), eyeglasses, contact lenses, hearing aids, wigs, and other prostheses. 6. Removal of nail polish and artificial nails if agency policy 7. Assurance that the patient has emptied his or her bladder 8. Siderails raised immediately before transport or after giving drugs that affect cognition or judgment 9. The call system within easy reach of the patient 10. The bed in a low position except during transport Correctly administer prescribed preoperative drugs: 1. Positively identify the patient (using the armband and asking the patient to state his or her name). 2. Ensure the correct drugs in the correct dosages via the correct route at the correct time are given and documented. See table 6 for the list of commonly used preoperative medications 3. A more common practice is for the preoperative drugs to be given after the patient is transferred to the preoperative area to make more accurate assessments and have last- minute discussions with a patient not yet affected by drugs. 4. The surgeon may prescribe a prophylactic antibiotic to be given within 60 minutes before the incision is made, as mandated by the Surgical Care Improvement Project (SCIP) core measures or during surgery to reduce the risk for a surgical site infection. Transfer the patient to the surgical suite along with the signed informed consent, completed preoperative checklist, and the patient Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  25 identification card. There are factors that influence the decision to transfer patient in a bed to the surgical suite. These factors include: o Age o Size o Physical condition Table 6. Commonly Used Preoperative Medications Classification Drug Purpose Antibiotics Cefazolin (Ancef) Prevent postoperative infection Anticholinergics Atropine (Isopto Decrease oral and respiratory Atropine) secretions Glycopyrrolate Prevent nausea and vomiting (Robinul) Provide sedation Scopolamine (Transderm-Scōp) Antidiabetics Insulin (Humulin R) Stabilize blood glucose Antiemetics Metoclopramide Increase gastric emptying (Reglan) Prevent nausea and vomiting Ondansetron (Zofran) Benzodiazepines Midazolam (Versed) Decrease anxiety, induce Diazepam (Valium) sedation, amnesic effects Lorazepam (Ativan) β-Blockers Labetalol (Normodyne) Manage hypertension Histamine (H2)- Famotidine (Pepcid) Decrease HCl acid secretion, receptor Ranitidine (Zantac) increase pH, decrease gastric antagonists volume Opioids Morphine (Duramorph) Relieve pain during Fentanyl (Sublimaze) preoperative procedures Considerations for Older Adults The older adult may have a variety of health-related issues that can have an impact on the planning of care and outcome of surgery, including: 1. Multiple comorbidities 2. Malnutrition 3. Endocrine dysfunction with reduced stress response 4. High risk for cardiopulmonary complications after surgery 5. High risk for delirium (e.g., related to unfamiliar surroundings, change in routine, drugs given, and other factors) 6. Risk of a fall and resultant injury 7. Dysfunction or impaired self-care abilities 8. Inadequate support systems Older adults have a higher risk for complications from operations and anesthesia due to the following reasons: Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  26 1. The immune system’s functions decreases. 2. There is delayed wound healing. 3. Exchange of gases can be altered due to general anesthetic agents and opioid analgesics. 4. Age-related changes in kidney and liver function may delay the elimination of anesthetic and analgesic agents increasing the risk for adverse reactions. 5. See table 7 for the list of other changes in older adults that may alter the operative response or risk. Teach the patient and family members about exercises and procedures like checking dressings, obtaining vital signs frequently to be performed after surgery. Teaching before surgery reduces apprehension and fear, increases cooperation and participation in care after surgery, and decreases respiratory and vascular complications. When the fear or anxiety level is high, explore the patient's feelings before beginning to teach the procedures. Discussion, demonstration with return demonstration, and practice by the patient aid in the ability to perform various breathing and leg exercises after surgery. Stress the need to begin exercises early in the recovery phase and to continue them, with 5 to 10 repetitions each, every 1 to 2 hours after surgery for at least the first 48 hours. Explain that the patient may need to be awakened for these activities. Table 7. Age-Related Changes as Surgical Risk Factors in Older Adults PHYSIOLOGIC NURSING INTERVENTIONS RATIONALES CHANGE Cardiovascular System Decreased cardiac Determine normal activity Knowing limits helps output levels and note when the prevent fatigue. Increased blood patient tires. pressure Decreased Monitor vital signs, Having baseline data peripheral peripheral pulses, and helps detect deviations. circulation capillary refill. Respiratory System Reduced vital Teach coughing and deep- Pulmonary exercises help capacity Loss of lung breathing exercises prevent pulmonary elasticity complications. Decreased Monitor respirations and Having baseline data oxygenation of breathing effort. helps detect deviations blood Renal/Urinary System Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  27 Decreased blood Monitor intake and output. Ongoing assessment helps flow to kidneys Assess overall hydration. detect fluid and Reduced ability to Monitor electrolyte status electrolyte imbalances excrete waste and decreased renal Decline in function. glomerular filtration rate Nocturia common Assist frequently with Frequent toileting helps toileting needs, especially prevent incontinence and at night. falls Neurologic System Sensory deficits Orient the patient to the An individualized Slower reaction time surroundings. Allow extra preoperative teaching Cognitive time for teaching the plan is developed based impairment patient. Keep patient on the patient's informed of activities orientation and any before implementation neurologic deficits Decreased ability to Provide for the patient's Safety measures help adjust to changes in safety. prevent falls and injury the surroundings Musculoskeletal System Increased incidence Assess the patient's Interventions help of deformities mobility. Teach turning and prevent complications of related to positioning. Encourage immobility. osteoporosis or ambulation arthritis Place on falls precautions, Safety measures help if indicated. prevent injury. Skin Dry with less Assess the patient's skin Having baseline data subcutaneous fat before surgery for lesions, helps detect changes and makes the skin at bruises, and areas of evaluate interventions greater risk for decreased circulation. damage; slower skin Pad bony prominences. Padding can protect at- healing increases risk areas risk for infection Use pressure-avoiding or Overlays can prevent pressure-reducing overlays pressure injury formation by redistributing body weight. Avoid applying tape to skin Tape removal damages thin skin. Teach the patient to change Changing position position at least every 2 frequently helps prevent hours. Use safe patient- reduced blood flow to an handling devices to avoid area and changes Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  28 shearing during patient external pressure movement. patterns Evaluation: Expected Patient Outcomes Relief of anxiety, evidenced when the patient: 1. Discusses with the anesthesiologist, anesthetist, or nurse anesthetist concerns related to types of anesthesia and induction. 2. Verbalizes an understanding of the preanesthetic medication and general anesthesia 3. Discusses last-minute concerns with the nurse or physician 4. Discusses financial concerns with the social worker, when appropriate 5. Requests visit with spiritual advisor, when appropriate 6. Appears relaxed when visited by health care team members Decreased fear, evidenced when the patient: 1. Discusses fears with health care professionals or a spiritual advisor, or both 2. Verbalizes an understanding of any expected bodily changes, including expected duration of bodily changes Understanding of the surgical intervention, evidenced when the patient: 1. Participates in preoperative preparation 2. Demonstrates and describes exercises that he or she is expected to perform postoperatively 3. Reviews information about postoperative care 4. Accepts preanesthetic medication, if prescribed 5. Remains in bed once premedicated 6. Relaxes during transportation to the operating room or unit 7. States rationale for use of side rails 8. Discusses postoperative expectations No evidence of preoperative complications Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  29 ACTIVITY 1: Read the situation carefully then answer what is asked. Write your answer in a separate sheet and send your answer to our google classroom. See the rubrics located in the appendix on how your activity will be evaluated. CLINICAL JUDGMENT CHALLENGE! You are caring for a patient who is scheduled for surgery, which must be performed under general anesthesia, to alleviate pain and stabilize the spinal column. During the preoperative assessment in which the patient's husband is present, you ask the patient if she has had anything to eat or drink since midnight. The patient states, “I have not eaten anything since midnight. I only drank a can of soda this morning before I came to the hospital.” The patient's husband immediately responds, “This won't keep her from having surgery, will it? I better not have to take off from work another day for this nonsense.” 1. What are the possible implications of the patient's consumption of soda before surgery? 2. What is your response to the patient's disclosure that she has consumed a can of soda on the morning of the scheduled surgery? 3. How would you address the husband's response? 4. Would you tell the surgeon about the patient's consumption of soda? Why or why not? 5. What teaching will you provide at this time? Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  30 PRETEST Before you start our second lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Intraoperative Nursing Care. Write your answer in a piece of paper. Good luck. Be honest to yourself. WORD HUNT: List down as many words as you can in the list below that is related to intraoperative nursing care. Words could be positioned horizontally, diagonally, or vertically, reading frontwards or backwards. A N E S T H E S I O L O G I S T F N G T D H J N V M N X C V B Y U F A C V E W A H I N T T R E B Y T J M G O F G R E R A D I N T R A O P E R A T I V E G H U G G G O J J O D A N M I C H A E T Y I O B H I N T R A V E N O U S G G S Y H K L L U F R O G G O Y U U A I S E H T S E N A B J U N E K C A B A P I N N A C E L K I N S S P I N A L M U S Y A H N D G R K K M L G H T I C F R S U R G E O N M L I E J O N N E E Y W Q U E N T E R S H O W L K C I R C U L A T I N G N U R S E H A P E A V Y O R E T H I N L E G H D S S A H K L O D O W N Y L O V E L N L E M O M E L F L I T R G M N O I I P D E V C A R I Y H G O W N I N G E L L O T R R E T R A E F L O Y W S I N G G R O P E D A H E F R P E R I P H E R A L N E R V E B L O C K B O B C E P I D U R A L C K S C I S S G “Do not be afraid or discouraged, for the Lord will personally go ahead of you. He will be with you; he will neither fail you nor abandon you.” Deuteronomy 31:8 Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  31 Lesson 2 Intraoperative Nursing Care Overview The intraoperative period begins when the patient enters the surgical suite (operating room [OR]) and ends at the time of transfer to the postanesthesia recovery area, SDS unit, or ICU. Nursing priorities in the OR are safety and patient advocacy by reducing, controlling, and managing many hazards. Surgeon SURGICAL Perioperative Surgical Nursing Staff TEAM Assistant/s MEMBERS Anesthesia Provider Surgical team members include: 1. The surgeon, a physician who assumes responsibility for the surgical procedure and any surgical judgments about the patient. 2. One or more surgical assistants who might be another physician (or resident or intern), an advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA), or surgical technologist. 3. The anesthesia provider, who gives anesthetic drugs to induce and maintain anesthesia and delivers other drugs as needed to support the patient during surgery Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  32 a. The anesthesiologist, a physician who specializes in giving anesthetic agents. b. The certified registered nurse anesthetist (CRNA), who is a registered nurse with additional education and credentials and who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist 4. Perioperative nursing staff, who may undergo orientation for 6 to 12 months a. The holding area nurse, who coordinates and manages the care of the patient in the presurgical holding area next to the main OR, assesses the patient's physical and emotional status, gives emotional support, answers questions, and provides additional education as needed. ACTION ALERT NURSING SAFETY PRIORITY Once the patient has been moved into the holding area or the OR, do not leave him or her alone. b. The scrub nurse sets up the sterile field, drapes the patient, and hands sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. This person also maintains an accurate count of sponges, sharps, instruments, and amounts of irrigation fluid and drugs used. An OR technician may also perform these tasks. Table 8 shows other responsibilities of a scrub nurse. c. The circulating nurse, who is responsible for coordinating all activities within that particular OR, sets up the OR and ensures that supplies, including blood products and diagnostic support, are available as needed. Table 9 enumerates the responsibilities of the circulating nurse. d. The specialty nurse may be in charge of a particular type of surgical specialty (e.g., orthopedic, cardiac, ophthalmologic) and is responsible for nursing care specific to patients needing that type of surgery. Table 8. Responsibilities of a Scrub Nurse Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  33 1. Reviews anatomy, 12. After the patient is positioned and physiology, and surgical prepped, assist in draping according to procedure. the type of procedure and the surgeon’s preference, bring the Mayo stand into position over the patient, making sure it does not rest on the patient, and assist the surgeon in securing sterile light handles for adjustment of the operating light. 2. Drape unsterile tables- 13. Anticipate the needs of the surgeon Mayo stand, skin and assistant (hand over the instruments preparation tray. needed in a desire and positive manner). 3. Arrange basin sets in their 14. Specimens are put in a specimen proper position/ place. container for Diagnostic exam/ evaluation. 4. Completes surgical hand 15. As the surgeon begins closure of the and arm scrub, and gowns wound, count sponges, sharps and and gloves self and other instruments with the circulator. Verify members of surgical team. that intraabdominal or other cavity packing materials and towels have been removed. 5. Arrange on the Mayo stand, 16. Maintain the sterility of the field the instrument and until the patient leaves the room. accessory items needed to create the primary incision. 6. Arrange other instruments 17. Put sterile dressings after skin and items on the closure is completed. instruments table. 7. Count sponges, surgical, 18. After care of the instruments. needles, other sharps and instruments with the circulator. 8. Secure surgical needles and 19. Monitors practices of aseptic all other sharps, including technique in self and others. knife blades. 9. Put blades on knife handles. 20. Keeps track of irrigation solutions used for calculation of blood loss. 10. Prepare sutures in the 21. Accepts, verifies, and reports sequence in which the medications used by surgeon and/or surgeon will use them ACP, including local anesthetics. (ligatures) free hand ties. 11. Routine procedure- gown and glove the surgeon as soon after they enter the room. Table 9. Responsibilities of a Circulating Nurse Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  34 1. Reviews anatomy, 19. Participates in surgical time-out. physiology, and surgical See Figure 8 the World Health procedure. Organization Surgical Safety Checklist. 2. Conducts a preprocedure 20. Place steps or platforms for team verification process and member who need them. assesses patient’s physical and emotional status. 3. Checks chart and relate 21. Anticipates the needs of the sterile pertinent data to team team. Be alert. members. 4. Plans and coordinates 22. Keep discarded sponges carefully intraoperative nursing care. collected, separated by sizes and counted according to the number they are packaged in. 5. In the absence of a holding 23. Assist the surgeon and the area nurse, the circulating anesthesia provider monitor fluid nurse also provides holding losses: blood, urine output, and others. area tasks. 6. Assist the sterile scrub 24. Know the condition of the patient at person by providing and all times- inform the OR manager of any opening sterile supplies marked changes, unanticipated needed to prepare for additional procedure or delays. arrival of the patient and the surgeon. 7. Check the surgeon’s 25. Prepare and label specimens for preference card. Collect transport to the laboratory. Label the supplies that will be needed specimen with these data: patient’s and get them organized. name, identification number and type and site of specimen. Requisition: date, name of surgeon, preoperative and postoperative diagnosis, surgical procedures, desired test, and tissue to be examined including its source. 8. Test all equipment before 26. During closure, count sponges, bringing the patient into sharps and instruments with the scrub the room. person. Report counts as correct or incorrect to the surgeon. Complete the count records. 9. Check with the scrub person 27. Send post-anesthesia care unit to see if additional supplies (PACU) stretcher or an intensive care or instruments are needed. unit (ICU) bed, or prepare the patient’s stretcher or bed with a clean sheet. Assist in room turnover. 10. Establish a baseline of table 28. Assist with dressing the surgical contents for the record, wound and managing the surgical count sponges, sharps, and drainage systems. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  35 instruments with the scrub person. 11. Attends and conducts a 29. Open the neck and back closures of brief assessment of the the surgeon’s and assistant’s gown so patient. they can remove them without contaminating themselves. 12. Transport and transfer 30. See that the patient is clean. patient to the operating bed. Ensure safety of the patient by putting safety belt. Then, positions the patient. 13. Assists with induction of 31. Transfer the patient on the anesthesia. Remain at the transport cart. patient’s side during anesthesia induction. Provide a quiet environment. 14. Attach the anesthesia 32. Maintains aseptic technique in all screen and other table required activities. Monitors practices attachments as needed. For of aseptic technique in self and others. electrosurgical unit, place a dispersive electrode pad in contact with the patient’s skin (avoid scar tissue and hairy or bony areas.). Help to turn over on overhead spotlight over the site of incision. 15. Inserts a Foley catheter if 33. Documents intraoperative care, needed. Scrubs the surgical events, interventions, and findings and site before the patient is completion of documents in the OR and draped with sterile drapes nursing records about the presence of drains or catheters, the length of the surgery, and a count of all sponges, "sharps” (needles, blades), and instruments. Verifies, dispenses, and records medications used, including local anesthetics. 16. Assist the gowning of the 34. Raise the side rails before the team. Fasten the back of patient is transported out of the OR. the scrub person’s gown. 17. Observe for any breaks in 35. Be sure the completed chart and sterile technique during proper records accompany the patient draping. and send other supplies as indicated. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  36 18. Assist the scrub person in 36. Communicating information about moving the Mayo stand and the patient's status to family members. instrument table into position being careful not to touch the drapes. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  37 Figure 8. World Health Organization Surgical Safety Checklist Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  38 Types of anesthesia and complications 1. General anesthesia (GA I. Descriptions/Characteristics a. GA is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system (CNS). b. The patient is unconscious and unaware and has loss of muscle tone and reflexes. c. Protective reflexes such as cough and gag reflexes are lost. d. Agents are administered by inhalation and IV injection. e. Gas anesthetic agents are administered by inhalation and are always combined with oxygen. f. Intravenous medications are used in combination with inhalation agents but it could also be used alone to promote moderate sedation. g. See figure 9 for the different delivery methods through inhalation. Table 10 presents the list of the inhalation and intravenous anesthetic agents and its advantages and disadvantages. Table 11 discusses the Phases of General Anesthesia. II. Complications a. It include malignant hyperthermia (MH), an acute, life-threatening complication of certain drugs in which skeletal muscle exposed to specific agents increases calcium levels and metabolism leading to acidosis, cardiac dysrhythmias, and a high body temperature. i. MH is a genetic disorder with an autosomal dominant pattern of inheritance and is most common in young, well-muscled men. ii. Drugs most associated with MH are halothane, enflurane, isoflurane, desflurane, sevoflurane, and succinylcholine. iii. When MH occurs, the treatment is intravenous dantrolene. b. An overdose of anesthesia can occur when the patient's metabolism and elimination are slower than expected, such as an older adult or one with liver or kidney dysfunction. c. Unrecognized hypoventilation with failure to exchange gases adequately can lead to Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  39 cardiac arrest, permanent brain damage, and death. d. Intubation complications from improper neck extension or anatomic differences in a patient can lead to broken or injured teeth and caps, swollen lips, or vocal cord trauma. e. Hemodynamic instability from medications, fluid loss, or dysrhythmias can contribute to brain or other organ damage. Figure 9. Different delivery methods through inhalation A. Laryngeal Mask Airway (LMA) B. Intranasal Intubation C. Oral Intubation Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  40 Table 11. Inhalation anesthetic agents and commonly used intravenous medications. Inhalation Anesthetic Agents Agent Advantages Disadvantages Implications/ Considerations VOLATILE LIQUIDS Halothane Not explosive Requires In addition to (Flouthane) or flammable skillful observation of Induction rapid administration pulse and and smooth to prevent respiration Useful in overdosage postoperatively, almost every May cause liver blood pressure type of surgery damage must be monitored Low incidence May produce frequently. of hypotension postoperative Requires nausea and special vomiting vaporizer for administration Enflurane Rapid induction Respiratory Observe for (Ethrane) and recovery depression may possible respiratory Potent analgesic develop rapidly, depression. Not explosive or along with ECG Administration with flammable abnormalities. Not epinephrine may compatible with cause ventricular epinephrine fibrillation. Isoflurane Rapid induction A profoundRespirations must (Forane) and recovery respiratory be monitored Muscle relaxants depressant closely and are markedly supported when potentiated. necessary. Sevoflurane Rapid induction Coughing and Monitor for (Ultrane) and excretion; laryngospasm; malignant minimal side trigger for hyperthermia. effects malignant hyperthermia Desflurane Rapid induction Respiratory Monitor for (Suprane) and emergence; irritation; trigger malignant rare organ for malignant hyperthermia, toxicity hyperthermia dysrhythmias. GASES Nitrous Oxide Induction and Poor relaxant Most useful in (N2O) recovery rapid Weak anesthetic conjunction with Nonflammable May produce other agents with Useful with hypoxia longer action oxygen for short Monitor for chest procedures Useful pain, hypertension, with other agents and stroke. Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  41 for all types of surgery Intravenous Anesthetic Agents Medication Common Usage Advantages Disadvantages Opioid Analgesic Agents Alfentanil Surgical analgesia Ultra-short acting –––––– (Alfenta) (5-10 min) analgesic agent; duration of action 0.5 h; bolus or infusion. Fentanyl Surgical Good May cause muscle or (Sublimaze) Analgesia; cardiovascular chest wall rigidity epidural infusion stability; duration for postoperative of action 0.5 h. analgesia; add to SAB Morphine Preoperative Inexpensive; Nausea and Sulfate (MS- pain; duration of action vomiting; histamine Contin) premedication 4-5 hours; release; postural euphoria; good decreased blood cardiovascular pressure and stability decrease systemic vascular resistance Remifentanil IV infusion for Easily titrated; New; expensive; (Ultiva) surgical very short requires mixing; analgesia; small duration; good may cause muscle boluses for brief, cardiovascular rigidity intense pain stability. Ultiva is rapidly metabolized by hydrolysis of the propanoic acid- methyl ester linkage by nonspecific blood and tissue esterases. Sufentanil Surgical analgesia Duration of action Prolonged (Sufenta) 0.5 h; prolonged respiratory analgesia depression exceptionally potent (5-10 times more than fentanyl); provides good stability in cardiovascular surgery Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  42 Depolarizing Muscle Relaxants Medication Common Usage Advantages Disadvantages Succinylcholine Relax skeletal Short duration; No known effect on muscles for rapid onset consciousness, pain surgery and threshold or orthopedic cerebration; manipulations; fasciculations, short procedures; postoperative intubation myalgias, dysrhythmias; raises serum potassium in tissue trauma, muscular disease, paralysis, burns; histamine release is slight; requires refrigeration Nondepolarizing Muscle Relaxants- Intermediate Onset and Duration Medication Common Usage Advantages Disadvantages Atracurium Intubation; No significant Requires besylate maintenance of cardiovascular or refrigeration; slight (tracrium) skeletal muscle cumulative histamine release; relaxation effects; good with pregnancy risk renal failure category C; do not mix with lactated Ringer’s solution or alkaline solutions such as barbiturates Cisatracurium Intubation; Similar to No histamine besylate maintenance of atracurium release (Nimbex) skeletal muscle relaxation Mivacurium Intubation; Short acting; Expensive in longer (Mivacron) maintenance of rapid metabolism cases skeletal muscle by plasma relaxation cholinesterase; used as bolus or infusion Rocuronium Intubation; Rapid onset (dose No known effect on (Zemuron) maintenance of dependent); consciousness, pain relaxation eliminates via threshold, or kidney and liver cerebration; vagolytic; may increase heart rate Vecuronium Intubation; No significant Requires mixing (Norcuron) maintenance of cardiovascular or relaxation cumulative effects, no histamine release Module I- NUPC 113: PERIOPERATIVE NURSING CARE DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  43 Nondepolarizing Muscle Relaxants- Longer Onset and Duration Medication Common Usage Advantages Disadvantages d-Tubocurarine Adjunct to - No known effect on anesthesia; consciousness, pain maintenance of threshold, or relaxation cerebration; might cause histamine release and transient ganglionic blockade Metocurine Maintenance of Good Slight histamine (Metubine) relaxation cardiovascular release stability Pancuronium Maintenance of - May cause increase (Pavulon) relaxation in heart rate and increase in blood pressure Intravenous Anesthetic Agents Medication Common Usage Advantages Disadvantages Diazepam Amnesia; Good sedation Long acting (Valium, Dizac) hypnotic; relieves anxiety; preoperative Etomidate Induction of Short-acting May cause brief (Amidate) general hypnotic; good period of apnea;