Week+3+Lecture+Slides+Intraoperative+Care+Nursing+002+_1_ 3.pdf
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Copyright © 2020 by Elsevier, Inc. All rights reserved. INTRAOPERATIVE CARE JEMMA CORNWALL Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 INTRAOPERATIVE CARE 3 Copyright © 2020 by Elsevier, Inc. All rights reserved. Conc...
Copyright © 2020 by Elsevier, Inc. All rights reserved. INTRAOPERATIVE CARE JEMMA CORNWALL Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 INTRAOPERATIVE CARE 3 Copyright © 2020 by Elsevier, Inc. All rights reserved. Conceptual Focus Gas Exchange Pain CONCEPTUAL FOCUS DURING Perfusion SURGERY Safety Tissue Integrity 4 Copyright © 2020 by Elsevier, Inc. All rights reserved. Surgical suite Controlled environment PHYSICAL Designed to minimize spread of pathogens ENVIRONMENT Allows smooth flow of patients, staff, and equipment to give safe surgical patient care 5 Copyright © 2020 by Elsevier, Inc. All rights reserved. Unrestricted zone People in street clothes interact with those in scrub attire PHYSICAL Holding area ENVIRONMENT Locker room Information areas Nursing station Control desk 6 Copyright © 2020 by Elsevier, Inc. All rights reserved. Semirestricted zone Peripheral support areas and corridors with only authorized staff Should wear clean surgical attire PHYSICAL Long sleeve jacket ENVIRONMENT Dedicated shoes or shoe covers Surgical head cover Mask that covers all head and facial hair Appropriate PPE 7 Copyright © 2020 by Elsevier, Inc. All rights reserved. Restricted zone Surgical suite (OR) PHYSICAL Sterile core ENVIRONMENT Masks worn and traffic minimized whenever sterile supplies are open 8 Copyright © 2020 by Elsevier, Inc. All rights reserved. Holding area PHYSICAL Semirestricted zone ENVIRONMENT Final identification and assessment Friends/family allowed 9 Copyright © 2020 by Elsevier, Inc. All rights reserved. AOD area Admission, observation, and discharge area PHYSICAL Early morning admissions ENVIRONMENT Outpatient surgery Same-day admission Inpatient holding 10 Copyright © 2020 by Elsevier, Inc. All rights reserved. Operating room Restricted zone PHYSICAL Geographically, environmentally, and ENVIRONMENT aseptically controlled Preferred location is next to PACU and surgical ICU Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 TRADITIONAL OPERATING ROOM Fig. 18-2 12 Copyright © 2020 by Elsevier, Inc. All rights reserved. Operating room Filters Controlled airflow PHYSICAL Positive air pressure ENVIRONMENT Narrow range of temperature and humidity Strict protocols for cleaning UV lighting 13 Copyright © 2020 by Elsevier, Inc. All rights reserved. Adjustable, easy-to-clean, and easy-to- move furniture is used Equipment is checked for proper PHYSICAL functioning and electrical safety ENVIRONMENT Lighting provides low- to high-intensity for precise view of surgical site Communication system is used 14 Copyright © 2020 by Elsevier, Inc. All rights reserved. Perioperative nurse Is a registered nurse (RN) Collaborates with rest of team SURGICAL Three domains Preoperative RN TEAM OR RN Serves as patient advocate throughout surgical experience Postanesthesia care unit (PACU) RN 15 Copyright © 2020 by Elsevier, Inc. All rights reserved. Scrub nurse SURGICAL Follows designated surgical hand antisepsis Gowned and gloved in sterile attire TEAM Prepares and manages the sterile field and instrumentation 16 Copyright © 2020 by Elsevier, Inc. All rights reserved. Circulating nurse SURGICAL Remains in unsterile field TEAM Facilitates progress of the procedure Maintains documentation 17 Copyright © 2020 by Elsevier, Inc. All rights reserved. LPN or surgical technologist SURGICAL May fill role of circulating or scrub nurse TEAM Must always have access to an RN 18 Copyright © 2020 by Elsevier, Inc. All rights reserved. Surgeon Physician who does the procedure Is responsible for SURGICAL Preoperative medical history Physical assessment TEAM Directing preoperative testing Postoperative management Obtaining informed consent Leading the surgical team 19 Copyright © 2020 by Elsevier, Inc. All rights reserved. Surgeon’s assistant can be a physician, RN first assistant (RNFA), PA, surgical resident or fellow, certified first assistant SURGICAL Holds retractors TEAM Helps with hemostasis and suturing May perform portions of procedure under surgeon’s direct supervision SURGICAL Registered nurse firstTEAM assistant (RNFA) Must have formal education Works collaboratively with the surgeon, patient, and surgical team CNOR nurses or nurse practitioner can complete RNFA program 20 RNFA can obtain certification (C-RNFA) Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Copyright © 2020 by Elsevier, Inc. All rights reserved. Anesthesia care provider (ACP) Administers anesthetic agents Manages vital life functions during perioperative period A Anesthesiologist has medical specialty Nurse anesthetist (CRNA) has master’s or doctorate Anesthesiologist assistant (AA) has master’s degree 22 Copyright © 2020 by Elsevier, Inc. All rights reserved. Before surgery Preoperative assessment NURSING Provides baseline data MANAGEMENT Provide physical and emotional comfort for patient and caregivers Provide teaching about surgery 23 Copyright © 2020 by Elsevier, Inc. All rights reserved. Before surgery Chart review History and physical examination NURSING Urinalysis MANAGEMENT CBC Serum electrolytes Chest x-ray ECG 24 Copyright © 2020 by Elsevier, Inc. All rights reserved. Admitting patient to OT NURSING Initial greeting MANAGEMENT Proper identification Human contact and warmth 25 Copyright © 2020 by Elsevier, Inc. All rights reserved. Admitting patient Reassessment Last-minute questions NURSING Final questioning about valuables, prostheses, MANAGEMENT last intake of food/fluid Confirm correct preoperative drugs given Cover patient’s hair 26 Copyright © 2020 by Elsevier, Inc. All rights reserved. Admitting patient to OT Complementary and alternative therapies NURSING Decrease anxiety MANAGEMENT Promote relaxation Reduce pain 27 Copyright © 2020 by Elsevier, Inc. All rights reserved. Circulating nurse responsible for implementing intraoperative plan of care NURSING Ongoing assessment MANAGEMENT Reassessment Adjusting care plan to promote best surgical outcomes 28 Copyright © 2020 by Elsevier, Inc. All rights reserved. Room preparation All entering OR wear surgical attire Electrical and mechanical equipment checked for proper functioning NURSING Aseptic technique practiced when opening and MANAGEMENT placing instruments Counts Scrub nurse is sterile, circulating nurse is not 29 Copyright © 2020 by Elsevier, Inc. All rights reserved. Transferring patient Patient transported into OR after preoperative assessment complete NURSING Wheels locked during transfer between beds MANAGEMENT Enough staff for safe patient handling; safety straps Monitor leads, BP cuff, pulse oximeter applied 30 Copyright © 2020 by Elsevier, Inc. All rights reserved. Scrubbing, gowning, and gloving Wet scrubbing Fingernails cleaned first Next each plane of fingers, palms, and NURSING forearms MANAGEMENT Distal to proximal Hands held away from scrubs and higher than elbows Waterless, alcohol-based agents Prewash hands and forearms with soap 31 Copyright © 2020 by Elsevier, Inc. All rights reserved. Scrubbing, gowning, gloving After surgical hand antisepsis NURSING Sterile gown MANAGEMENT Two pair of gloves Once gowned and gloved, sterile items can be manipulated and organized Copyright © 2020 by Elsevier, Inc. All rights reserved. 32 SURGICAL ATTIRE Fig. 18-3 33 Copyright © 2020 by Elsevier, Inc. All rights reserved. Basic aseptic technique Center of sterile field is site of surgical incision NURSING Only sterilized items in sterile field MANAGEMENT OSHA and AORN guidelines Standard and transmission-based precautions Use of personal protective equipment 34 Copyright © 2020 by Elsevier, Inc. All rights reserved. Assisting anesthesia care provider NURSING Understand effects of anesthetic agents MANAGEMENT Know location of emergency equipment and drugs and equipment 35 Copyright © 2020 by Elsevier, Inc. All rights reserved. Assisting anesthesia care provider Circulating nurse may place monitoring devices on patient NURSING Remain at patient’s side to ensure safety during MANAGEMENT general anesthesia Measure BP Help maintain patient airway 36 Copyright © 2020 by Elsevier, Inc. All rights reserved. Positioning of patient Accessibility of operative site NURSING Administering and monitoring of anesthetic MANAGEMENT agents Maintaining patient airway 37 Copyright © 2020 by Elsevier, Inc. All rights reserved. Positioning of patient Provide correct musculoskeletal alignment NURSING Prevent pressure on nerves, skin over bony MANAGEMENT prominences, earlobes, eyes Provide for adequate thoracic excursion 38 Copyright © 2020 by Elsevier, Inc. All rights reserved. Positioning of patient Prevent occlusion of arteries and veins NURSING Provide modesty in exposure MANAGEMENT Recognize and respect needs such as pain or deformities 39 Copyright © 2020 by Elsevier, Inc. All rights reserved. Positioning of patient Prevent injury Patient will not feel pain impulses because NURSING of anesthesia MANAGEMENT Secure extremities Provide adequate padding and support Have physical and mechanical help Co py Stop rig ht © 20 20 Lecture by El se vie r, In Slide Here c. All rig ht s re se rv Remaining Slides To Be Continued Next Lecture 40 ed. 41 Copyright © 2020 by Elsevier, Inc. All rights reserved. Preparing surgical site Mechanically scrub or cleanse around surgical NURSING site with antimicrobial agent MANAGEMENT Clean area to dirty area Allow to fully dry Surgical site is draped 42 Copyright © 2020 by Elsevier, Inc. All rights reserved. Safety considerations Infection NURSING Physical trauma MANAGEMENT Physiologic effects of surgery Proper communication is essential Copyright © 2020 by Elsevier, Inc. All rights reserved. 43 SAFETY CONSIDERATIONS Time Out and Surgical Checklist The National Patient Safety Goals (NPSGs) require a pre-procedure verification process.11 This includes verifying relevant documentation (e.g., history and physical assessment, signed consent forms, nursing, and pre-anesthetic assessment and the results of any diagnostic studies (e.g., x-rays, biopsy reports). Blood products, implants, devices, and special equipment we expect to be used must be available. Copyright © 2020 by Elsevier, Inc. All rights reserved. 44 SAFETY CONSIDERATIONS Anaphylactic Reactions Anesthetic agents, antibiotics, blood products, and latex may cause allergic reactions. Anaphylaxis is the most severe form of an allergic reaction, with life-threatening pulmonary and circulatory complications. Vigilance and rapid intervention are essential. An anaphylactic reaction causes hypotension, tachycardia, bronchospasm, and pulmonary edema. Anesthesia may mask the initial manifestations of anaphylaxis. Latex allergy has become a concern in the surgical setting. Gloves, catheters, and many devices contain natural rubber latex. Latex allergy protocols in each agency help to provide Copyright © 2020 by Elsevier, Inc. All rights reserved. 45 SAFETY CONSIDERATION Malignant hyperthermia (MH) Malignant hyperthermia (MH) is a rare disorder characterized by hyperthermia with skeletal muscle rigidity. It can result in death. MH occurs in genetically susceptible people exposed to certain anesthetic agents. Succinylcholine (Anectine), especially when given with volatile inhalation agents, is the primary trigger of MH. Other factors include stress, trauma, and heat. When MH does occur, it is usually during general anesthesia. It may occur in the recovery period, too. MH can result in cardiac arrest and death. The definitive treatment of MH is the prompt administration of dantrolene (Dantrium, Ryanodex).14 Dantrolene slows metabolism, reduces muscle contraction, and mediates the catabolic processes associated with MH. Treatment also involves turning off anesthetic agents, providing 100% oxygen, and actively cooling the patient (ice packs in the groin, axilla and giving chilled IV fluids). MH can also cause hyperkalemia, disseminated intravascular coagulation, and compartment syndrome.14 46 Copyright © 2020 by Elsevier, Inc. All rights reserved. Communication : SBAR SURGICAL Situation Background TEAM Assessment Recommendations PHYSICAL ENVIRONMENT Intra –Op Holding area Surgical Care Improvement Project (SCIP) measures include Prophylactic antibiotic within 30 to 60 minutes before surgical incision Patient warming Applying intermittent pneumatic compression devices (IPCs) to prevent DVT Copyright © 2020 by Elsevier, Inc. All rights reserved. 47 PHYSICAL ENVIRONMENT Holding area National Patient Safety Goals (NPSGs) require a pre- procedure verification process, including: Verification of relevant documentation Results of any diagnostic studies Needed blood products, implants, special equipment available Procedure site marked by surgeon Copyright © 2020 by Elsevier, Inc. All rights reserved. 48 NURSING MANAGEMENT After surgery ACP anticipates end of procedure Gives proper types and doses of anesthetic agents so that effects will be minimal at end of surgery ACP goes with patient to PACU Hand-off includes Patient’s status Procedure done Copyright © 2020 by Elsevier, Inc. All rights reserved. 49 ANESTHESIA Anesthetic technique and agents are chosen by the ACP Contributing factors include Physical and mental status Age Allergies and pain history Expertise of the ACP Factors related to the procedure Copyright © 2020 by Elsevier, Inc. All rights reserved. 50 ANESTHESIA American Society of Anesthesiologists (ASA) Physical Status Classification system Scale of P1 to P6 Represents patient immediately before surgery P1= healthy P6= brain-dead Copyright © 2020 by Elsevier, Inc. All rights reserved. 51 CLASSIFICATION OF ANESTHESIA Moderate to deep sedation Procedures done outside the OR Presence of ACP not needed May be administered by an RN under direct supervision of a physician Copyright © 2020 by Elsevier, Inc. All rights reserved. 52 53 Copyright © 2020 by Elsevier, Inc. All rights reserved. CLASSIFICATION OF ANESTHESIA Monitored Anesthesia Care (MAC) Used for diagnostic or therapeutic procedures done in or outside the OR Includes varying levels of sedation, analgesia, and anxiolysis Must be administered by an ACP Assessment and management of physiologic problems is critical Copyright © 2020 by Elsevier, Inc. All rights reserved. 54 CLASSIFICATION OF ANESTHESIA General anesthesia Total IV anesthesia (TIVA) Newer inhalation agents Used for Procedures of significant duration Need skeletal muscle relaxation Require uncomfortable operative positions Require control of ventilation Copyright © 2020 by Elsevier, Inc. All rights reserved. 55 CLASSIFICATION OF ANESTHESIA General anesthesia IV agents Beginning of all routine general anesthesia Hypnotic, anxiolytic, or dissociative agent Induce sleep with rapid onset of action Long enough for placement of LMA or ET tube Copyright © 2020 by Elsevier, Inc. All rights reserved. 56 CLASSIFICATION OF ANESTHESIA Adjuncts to general anesthesia Neuromuscular blocking agents Facilitate endotracheal intubation Relaxation/paralysis of skeletal muscles Interrupt transmission of nerve impulses at neuromuscular junction Copyright © 2020 by Elsevier, Inc. All rights reserved. 57 CLASSIFICATION OF ANESTHESIA Neuromuscular blocking agents Classified as depolarizing or nondepolarizing muscle relaxants Duration of effects may be longer than the procedure Reversal agents may not be effective in eliminating residual effects Copyright © 2020 by Elsevier, Inc. All rights reserved. 58 CLASSIFICATION OF ANESTHESIA Neuromuscular blocking agents Observe closely for airway patency and adequacy of respiratory muscle movement Lack of movement or poor return of reflexes and strength may indicate need for ventilator Copyright © 2020 by Elsevier, Inc. All rights reserved. 59 CLASSIFICATION OF ANESTHESIA Adjuncts to general anesthesia Antiemetics Prevent nausea and vomiting associated with anesthesia Copyright © 2020 by Elsevier, Inc. All rights reserved. 60 CLASSIFICATION OF ANESTHESIA Local anesthesia Loss of sensation without loss of consciousness Types Topical Ophthalmic Nebulized Injectable Copyright © 2020 by Elsevier, Inc. All rights reserved. 61 CLASSIFICATION OF ANESTHESIA Regional anesthesia (Block) Injection to a central nerve or group of nerves Innervates a site remote to the point of injection Used as preoperative analgesia, during surgery, and after surgery Copyright © 2020 by Elsevier, Inc. All rights reserved. 62 CLASSIFICATION OF ANESTHESIA Local and regional anesthesia Little systemic absorption Rapid recovery Discharge with continued postoperative analgesia No accompanying cognitive dysfunction Copyright © 2020 by Elsevier, Inc. All rights reserved. 63 CLASSIFICATION OF ANESTHESIA Methods of administration Spinal anesthesia Injection of local anesthetic into CSF in the subarachnoid space Usually below L2 Autonomic, sensory, and motor blockade Copyright © 2020 by Elsevier, Inc. All rights reserved. 64 CLASSIFICATION OF ANESTHESIA Methods of administration Epidural block Injection of local anesthetic into epidural space Does not enter CSF Binds to nerve roots as they enter and exit the spinal cord Sensory pathways blocked but motor fibers are still intact Copyright © 2020 by Elsevier, Inc. All rights reserved. 65 Copyright © 2020 by Elsevier, Inc. All rights reserved. 66 SPINAL AND EPIDURAL ANESTHESIA Fig. 18-6 CLASSIFICATION OF ANESTHESIA Spinal and epidural anesthesia Observe closely for signs of autonomic nervous system (ANS) blockade Bradycardia Hypotension Nausea/vomiting Copyright © 2020 by Elsevier, Inc. All rights reserved. 67 GERONTOLOGIC CONSIDERATIONS Anesthetic drugs need be carefully titrated Postoperative delirium common Possible communication difficulties Risk for injury from tape, electrodes Osteoporosis or osteoarthritis Copyright © 2020 by Elsevier, Inc. All rights reserved. 68 CATASTROPHIC EVENTS IN THE OR Malignant hyperthermia (MH) Rare disorder Autosomal dominant trait Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium Copyright © 2020 by Elsevier, Inc. All rights reserved. 69 CATASTROPHIC EVENTS IN THE OR Malignant hyperthermia Succinylcholine (Anectine), especially given with volatile inhalation agents, is primary trigger Other factors include stress, trauma, and heat Usually occurs under general anesthesia but may also occur in recovery Copyright © 2020 by Elsevier, Inc. All rights reserved. 70 CATASTROPHIC EVENTS IN THE OR Malignant hyperthermia Tachycardia Tachypnea Hypercarbia Ventricular dysrhythmias Rise in body temperature NOT an early sign Can result in cardiac arrest and death Copyright © 2020 by Elsevier, Inc. All rights reserved. 71 CATASTROPHIC EVENTS IN THE OR Malignant hyperthermia Definitive treatment is prompt administration of Dantrolene Slows metabolism Reduces muscle contraction Mediates catabolic processes Prevention includes taking careful family history Copyright © 2020 by Elsevier, Inc. All rights reserved. 72 73 REFERENCE Please Read Intraoperative Care Sherpath Chapter 19 Copyright © 2020 by Elsevier, Inc. 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