Chapter 19 Intraoperative Care PDF

Chapter 19 Intraoperative Care  Intraoperative Care (1 of 2)  Historically, took place in OR  Now many are done in outpatient settings  ↑ Minimally invasive surgery (MIS)  Endoscopes  Robotics  Other advanced technology...

Chapter 19 Intraoperative Care  Intraoperative Care (1 of 2)  Historically, took place in OR  Now many are done in outpatient settings  ↑ Minimally invasive surgery (MIS)  Endoscopes  Robotics  Other advanced technology 2  Intraoperative Care (2 of 2)  MIS leads to decreased  Blood loss  Incision size  Pain  Recovery time  Hospital length of stay 3  Physical Environment (1 of 9)  Surgical department  Controlled environment  Designed to minimize spread of pathogens  Allows smooth flow of patients, staff, and equipment for safe surgical patient care 4  Physical Environment (2 of 9)  Unrestricted zone  People in street clothes interact with those in scrub attire  Point of entry for patients, staff, and information Preoperative holding area Staff locker rooms Nursing station, control desk 5  Physical Environment (3 of 9)  Semirestricted zone  Surrounding support areas and corridors with only authorized staff  Should wear clean surgical attire Scrub attire Long-sleeved jacket Dedicated shoes or shoe covers Surgical head cover Appropriate PPE 6  Physical Environment (4 of 9)  Restricted zone  Surgical suite (OR)  Sterile core  Masks worn and traffic minimized when sterile supplies are open 7  Physical Environment (5 of 9)  Preoperative holding area  Unrestricted zone  Patient identification and assessment 8  Physical Environment (6 of 9)  AOD area  Admission, observation, and discharge unit Early morning admissions  Outpatient surgery  Same-day admission  Inpatient holding before surgery 9  Case Study (1 of 7)  M.C., a 56-year-old male, comes to the surgical suite with his girlfriend the morning of his scheduled surgery to replace his left knee.  He has a diagnosis of osteoarthritis of his left knee, as well as a history of hypertension. 10  Physical Environment (7 of 9)  Operating room  Restricted zone Geographically, environmentally, and aseptically controlled  Preferred location is next to PACU and surgical ICU Quick transport after surgery Close proximity to anesthesia staff 11 Traditional Operating Room Fig. 19.2 12  Physical Environment (8 of 9)  Operating room  Filters  Controlled airflow  Positive air pressure  Temperature and humidity controlled  UV lighting  Strict protocols for cleaning 13  Physical Environment (9 of 9)  Adjustable, easy-to-clean, and easy-to-move furniture  Equipment is checked frequently to ensure proper functioning and electrical safety  Lighting designed for precise view of surgical site  Communication system is used 14  Surgical Team (1 of 8)  Perioperative nurse  Is a registered nurse (RN)  Works with rest of surgical team  Three domains Preoperative RN OR RN  Serves as patient advocate during surgery Postanesthesia care unit (PACU) RN 15  Surgical Team (2 of 8)  Scrub nurse (sterile)  Follows designated surgical hand antisepsis  Gowned and gloved in sterile attire  Prepares and manages the sterile field and instrumentation 16  Surgical Team (3 of 8)  Circulating nurse  Remains in unsterile field  Facilitates progress of the procedure  Keeps documentation 17  Surgical Team (4 of 8)  LPN/VN or surgical technologist  May fill role of circulating or scrub nurse  An RN must supervise the LPN/VN or surgical technologist 18  Surgical Team (5 of 8)  Surgeon  Physician who does the surgery  Is responsible for Preoperative medical history Physical assessment Directing preoperative testing Postoperative management Obtaining informed consent Leading the surgical team 19  Surgical Team (6 of 8)  Surgeon’s assistant can be a physician, RN first assistant (RNFA), PA, surgical resident or fellow, medical student, certified surgical first assistant  Holds retractors  Helps with hemostasis and suturing  May perform some parts of procedure under surgeon’s direct supervision 20  Surgical Team (7 of 8)  Registered nurse first assistant (RNFA)  Must have formal education  Works collaboratively with the surgeon, patient, and surgical team  CNOR nurses or nurse practitioner can complete RNFA program  RNFA can obtain certification (C-RNFA) 21  Case Study (2 of 7)  The anesthesiologist meets with M.C. in the holding area.  The purpose is to assess and obtain informed consent for the general anesthesia to be provided during his surgery. 22  Surgical Team (8 of 8)  Anesthesia care provider (ACP)  Administers anesthetic agents  Manages vital life functions during perioperative period Anesthesiologist has medical specialty Nurse anesthetist (CRNA) has master’s or doctorate Anesthesiologist assistant (AA) has master’s degree 23  Nursing Management (1 of 20)  Patient before surgery  Preoperative assessment Provides baseline data  Psychosocial assessment Provide physical and emotional comfort for patient and caregivers Provide teaching about surgery 24  Nursing Management (2 of 20)  Before surgery  Chart review History and physical examination Urinalysis CBC Serum electrolytes Chest x-ray ECG 25  Nursing Management (3 of 20)  Admitting patient  Initial greeting  Proper identification  Supportive welcome to the setting. 26  Case Study (3 of 7)  When M.C. arrives in the holding area, he appears anxious and answers questions with reluctance.  He shares that this is the first time he is having surgery.  He reports pain of 6 in his right knee on a 0 to 10 scale. 27  Nursing Management (4 of 20)  Admitting patient  Reassessment  Last-minute questions  Ask about valuables, prostheses, last intake of food/fluid  Confirm ordered preoperative drugs given  Cover patient’s hair 28  Nursing Management (5 of 20)  Admitting patient  Complementary and alternative therapies Decrease anxiety Promote relaxation Reduce pain 29  Nursing Management (6 of 20)  Circulating nurse responsible for implementing intraoperative plan of care  Ongoing assessment  Reassessment  Adjusting care plan to promote best surgical outcomes 30  Nursing Management (7 of 20)  Room preparation  To ensure privacy, prevention of infection, and safety  Extra staff and special equipment may be needed for transfer of obese patient  Special equipment may also be used. 31  Nursing Management (8 of 20)  Room preparation  All entering OR wear surgical attire  Electrical and mechanical equipment checked for proper functioning  Aseptic technique practiced when opening and placing instruments Items counted Scrub nurse is sterile, circulating nurse is not 32  Nursing Management (9 of 20)  Transferring patient  Patient transported into OR after preoperative assessment complete  Wheels locked during transfer between beds  Enough staff for safe patient handling; safety straps  Monitor leads, BP cuff, pulse oximeter applied 33  Case Study (4 of 7)  M.C. will soon be transported to the OR for his procedure to begin.  His left knee is marked by the surgeon.  He has an antiembolic stocking and IPC on his right leg, an IV of D5 ½ NS infusing in his right hand, and orders for cefazolin 1 gram IV and insertion of a urinary catheter. 34  Nursing Management (10 of 20)  Scrubbing, gowning, and gloving  Wet scrubbing Fingernails cleaned first Next each plane of fingers, palms, and forearms  Distal to proximal  Hands held away from surgical attire and higher than elbows  Waterless, alcohol-based agents Prewash hands and forearms with soap Apply alcohol-based product and rub until dry 35  Nursing Management (11 of 20)  Scrubbing, gowning, gloving  After surgical hand antisepsis Sterile gown Two pair of gloves  Once gowned and gloved, sterile items can be touched and organized 36  Surgical Attire Fig. 19.3 37  Nursing Management (12 of 20)  Basic aseptic technique  Center of sterile field is site of surgical incision  Only sterilized items in sterile field  OSHA and AORN guidelines  Standard and transmission-based precautions  Engineering and work practice controls  Using personal protective equipment 38  Nursing Management (13 of 20)  Assisting anesthesia care provider (ACP)  Understand effects of anesthetic agents  Know location of emergency drugs and equipment 39  Nursing Management (14 of 20)  Assisting anesthesia care provider  Circulating nurse may place monitoring devices on patient  Remain at patient’s side to ensure safety during general anesthesia Measure BP Help maintain patient airway Vital communication link for the ACP to other departments 40  Nursing Management (15 of 20)  Positioning patient to allow for  Accessibility of operative site  Administering and monitoring of anesthetic agents  Maintaining patient airway 41  Nursing Management (16 of 20)  Positioning of patient  Provide correct musculoskeletal alignment  Prevent undue pressure on nerves, skin over bony prominences, earlobes, eyes  Provide for adequate thoracic excursion 42  Nursing Management (17 of 20)  Positioning of patient  Recognize and respect needs such as previously assessed pain or deformities  Secure extremities  Provide adequate padding and support  Have physical and mechanical help 43  Nursing Management (18 of 20)  Positioning of patient  Anesthesia blocks the sensory nerve impulses  Position changes affect where the pooling of blood occurs  Hypovolemia and cardiovascular disease can further compromise the patient’s status  Correctly place the grounding pad and all electrosurgical equipment to prevent injury from burns or fire 44  Case Study (5 of 7)  M.C. is transferred to the OR table.  The circulating nurse begins to prepare him for surgery. 45  Nursing Management (19 of 20)  Preparing surgical site  Mechanically scrub or cleanse around surgical site with antimicrobial agent Scrub from clean area to dirty area Allow to fully dry  Surgical site is then draped 46  Case Study (6 of 7)  With M.C. positioned for surgery, the circulating nurse begins to prepare his leg for surgery. 47  Nursing Management (20 of 20)  Safety considerations  Infection  Physical trauma  Physiologic effects of surgery  Proper and clear communication is essential 48  Surgical Team  Communication  Situation  Background  Assessment  Recommendations 49  Physical Environment (1 of 2)  Holding area  Surgical Care Improvement Project (SCIP) measures include Prophylactic antibiotic with 30 to 60 minutes before surgical incision Applying a warming blanket Applying intermittent pneumatic compression devices (IPCs) 50  Physical Environment (2 of 2)  Holding area  NationalPatient Safety Goals (NPSGs) require a preprocedure verification process, including:  Verification of relevant documentation  Results of any diagnostic studies  Needed blood products, implants, special equipment available  Procedure site marked by surgeon 51  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 52  Case Study (7 of 7)  M.C.’s surgery is completed and he is transferred to the PACU.  He has a drain in his left knee.  His left leg is wrapped with an elastic bandage from ankle to thigh.  He has a non-rebreather oxygen mask on at 100% and his IV continues to infuse at 100 mL/hr. 53 Anesthesia  Anesthesia (1 of 2)  Anesthetic technique and agents are chosen by the ACP in collaboration with the surgeon and patient  Contributing factors include patient’s  Current physical and mental status  Age  Allergies and pain history  Expertise of the ACP  Factors related to the procedure 55  Anesthesia (2 of 2)  American Society of Anesthesiologists (ASA) physical status classification system  ASA1 to ASA6  Represents patient immediately before surgery ASA1= healthy ASA6= brain-dead 56  Classification of Anesthesia (1 of 21)  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 57  Classification of Anesthesia (2 of 21)  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 any physiologic problems is critical May be necessary to change to general anesthesia during the procedure 58  Classification of Anesthesia (3 of 21)  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 59  Classification of Anesthesia (4 of 21)  General anesthesia  IV induction agent Beginning of all routine general anesthesia  Hypnotic, anxiolytic, or dissociative agent  Induce sleep rapidly, lasts only a few minutes  Long enough for placement of LMA or ET tube 60  Classification of Anesthesia (5 of 21)  General anesthesia  Inhalation agents Volatile liquids or gases Enter the body through alveoli Easy administration and rapid excretion Some are irritating to respiratory tract Once initiated, use ET tube or LMA Complications include coughing, laryngospasm, and increased secretions 61  Classification of Anesthesia (6 of 21)  General anesthesia  Rarelylimited to one agent  Adjuncts Drugs added to the anesthetic regimen Synergistic or antagonistic effects  Dissociative anesthesia Interrupts associative brain pathways while blocking sensory pathways Ketamine (Ketalar) 62  Classification of Anesthesia (7 of 21)  Adjuncts to general anesthesia  Opioids Sedation and analgesia Induction and maintenance intraoperatively Pain management postoperatively Respiratory depression 63  Classification of Anesthesia (8 of 21)  Adjuncts to general anesthesia  Benzodiazepines Premedication for amnesia Induction of anesthesia Monitored anesthesia care 64  Classification of Anesthesia (9 of 21)  Adjuncts to general anesthesia  Neuromuscular blocking agents Facilitate endotracheal intubation Relaxation/paralysis of skeletal muscles Interrupt transmission of nerve impulses at neuromuscular junction 65  Classification of Anesthesia (10 of 21)  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 66  Classification of Anesthesia (11 of 21)  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 67  Classification of Anesthesia (12 of 21)  Adjuncts to general anesthesia  Antiemetics Prevent nausea and vomiting associated with anesthesia 68  Classification of Anesthesia (13 of 21)  Local anesthesia  Lossof sensation without loss of consciousness  Types Topical Ophthalmic Nebulized Injectable 69  Classification of Anesthesia (14 of 21)  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 70  Classification of Anesthesia (15 of 21)  Local and regional anesthesia  Little systemic absorption Rapid recovery Discharge with continued postoperative analgesia No accompanying cognitive dysfunction 71  Classification of Anesthesia (16 of 21)  Regional anesthesia  Disadvantages Possible technical problems Discomfort at injection site Inadvertent vascular injection leading to local anesthetic systemic toxicity (LAST)  Confusion, metallic taste, dizziness  Seizures, coma, and dysrhythmias may occur  Treatment involves lipid emulsion infusion ,respiratory and cardiovascular support 72  Classification of Anesthesia (17 of 21)  Methods of administration  Topical Creams, ointments, aerosols, liquids Apply 30 to 60 minutes before procedure  Local infiltration Inject agent into tissues through which incision will pass 73  Classification of Anesthesia (18 of 21)  Methods of administration  Regional nerve block RN may aid ACP in administering block Must be familiar with drugs, including  Methods of administration  Adverse and toxic effects Properly position the patient, monitor vital signs, apply oxygen therapy, and use supporting devices 74  Classification of Anesthesia (19 of 21)  Methods of administration  Spinal anesthesia Injection of local anesthetic into CSF in the subarachnoid space Usually below level of L2 Autonomic, sensory, and motor blockade 75 Spinal and Epidural Anesthesia Fig. 19.6 76  Classification of Anesthesia (20 of 21)  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 77  Classification of Anesthesia (21 of 21)  Spinal and epidural anesthesia  Observe closely for signs of autonomic nervous system (ANS) blockade Bradycardia Hypotension Nausea and vomiting 78  Gerontologic Considerations  Anesthetic drugs need be carefully titrated  Postoperative delirium common  Possible communication difficulties  Risk for injury from tape, electrodes, warming and cooling blankets, certain dressings  Osteoporosis or osteoarthritis  Risk for perioperative hypothermia 79  Perioperative Crisis Events (1 of 6)  Anaphylactic reactions  Anesthetic agents, antibiotics, blood products, and latex may cause allergic reactions  Vigilance and rapid intervention are essential  Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema 80  Perioperative Crisis Events (2 of 6)  Malignant hyperthermia (MH)  Rare disorder characterized by hyperthermia with skeletal muscle rigidity  Autosomal dominant trait Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium Leads to muscle contraction, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac problems Tachycardia, tachypnea, hypercarbia, and ventricular dysrhythmias may occur but are nonspecific to MH 81  Perioperative Crisis Events (3 of 6)  Malignant hyperthermia  Succinylcholine (Anectine), especially given with volatile inhalation agents, is primary trigger  Other factors include stress, trauma, and heat  Usually occurs during general anesthesia but may also occur in recovery 82  Perioperative Crisis Events (4 of 6)  Malignant hyperthermia  Diagnosed after ruling out other causes  Rise in body temperature NOT an early sign  Can result in cardiac arrest and death 83  Perioperative Crisis Events (5 of 6)  Malignant hyperthermia  Definitive treatment is prompt administration of Dantrolene (Dantrium, Ryanodex) Slows metabolism Reduces muscle contraction Mediates catabolic processes  Provide 100% oxygen and actively cool patient 84  Perioperative Crisis Events (6 of 6)  Malignant hyperthermia  Prevention includes taking careful family history  Teach patients with MH so that family members may consider being genetically tested 85 Audience Response Question (1 of 2) During admission of the patient to the holding area or operating room before surgery, the perioperative nurse must: a. verify the patient’s understanding of the risks of surgery. b. ensure the patient’s identity with a formal identification process. c. prepare the skin by scrubbing the surgical site with an antimicrobial agent. d. perform a preoperative assessment with a patient history and physical examination. 86 Audience Response Question (2 of 2) Answer: B ensure the patient’s identity with a formal identification process. 87 Audience Response Question (1 of 2) During the administration of any regional anesthetic, it is most important that the nurse: a. monitor for ascending neurologic depression and unconsciousness. b. ensure that airway equipment, emergency drugs, and monitors are immediately available. c. monitor the patient’s response to the anesthesia, assessing the extent of loss of sensation. d. ensure that reversal drugs such as anticholinesterase agents (e.g., neostigmine) are available in case of respiratory arrest. 88 Audience Response Question (2 of 2) Answer: B ensure that airway equipment, emergency drugs, and monitors are immediately available 89