Intraoperative Care Overview PDF

Intraoperative Care Overview Historically, surgery was performed in the operating room (OR), but now many surgeries are done in outpatient settings. Minimally invasive surgery (MIS) uses endoscopes, robotics, and other advanced technology. MIS reduces blood loss, incision size, pain, recovery...

Intraoperative Care Overview Historically, surgery was performed in the operating room (OR), but now many surgeries are done in outpatient settings. Minimally invasive surgery (MIS) uses endoscopes, robotics, and other advanced technology. MIS reduces blood loss, incision size, pain, recovery time, and hospital length of stay. The surgical department has a controlled environment to minimize pathogen spread and ensure safe patient care. The operating room is geographically, environmentally, and aseptically controlled, with a preferred location next to the PACU and surgical ICU. The operating room features filters, controlled airflow, temperature and humidity, UV lighting, and strict cleaning protocols. The perioperative nurse, a registered nurse (RN), works with the rest of the surgical team and serves as a patient advocate during surgery. The surgical team includes a scrub nurse (sterile), a circulating nurse, a LPN/VN or surgical technologist, and a surgeon. Surgical Team Overview The surgical team includes a surgeon's assistant, RN first assistant (RNFA), PA, surgical resident or fellow, medical student, and certified surgical first assistant. The anesthesiologist meets with the patient to assess and obtain informed consent for general anesthesia. The anesthesia care provider (ACP) administers anesthetic agents and manages vital life functions during the perioperative period. The patient is admitted before surgery, with a chart review, history and physical examination, urine analysis, CBC, serum electrolytes, chest x-ray, and ECG. The patient is admitted with an initial greeting, proper identification, and a supportive welcome to the setting. The patient is admitted with a pain score of 6 in his right knee on a 0 to 10 scale. The patient is admitted with a reassessment, last-minute questions, and confirmation of ordered preoperative drugs. The circulating nurse implements the intraoperative plan of care and adjusts the care plan to promote best surgical outcomes. Room preparation ensures privacy, infection prevention, and safety, with extra staff and special equipment needed for obese patients. The patient is transported into the OR after preoperative assessment complete, with wheels locked during transfer between beds. The patient is marked for his procedure and is given antiembolic stocking, IPC, IV of D5 ½ NS infusing in his right hand, and orders for cefazolin 1 gram IV and insertion of a urinary catheter. The patient is then scrubbed, gowned, and gloved, with sterile items in a sterile field. Anesthesia Care Provider (ACP) Responsibilities and Procedures Assisting Anesthesia Care Provider (ACP) Responsibilities Understanding effects of anesthetic agents. Knowing location of emergency drugs and equipment. Monitoring patient's blood pressure and maintaining patient airway. Providing vital communication link for ACP to other departments. Positioning of Patient Correct musculoskeletal alignment. Preventing undue pressure on nerves, skin over bony prominences, earlobes, eyes. Providing adequate thoracic excursion. Recognizing and respecting needs such as previously assessed pain or deformities. Secure extremities. Providing adequate padding and support. Having physical and mechanical help. Preparing Surgical Site Mechanically cleansing around surgical site with antimicrobial agent. Allowing to fully dry and draped surgical site. Safety Considerations Infection, physical trauma, and physiological effects of surgery. Proper and clear communication is essential. Communication and Physical Environment Holding area and Surgical Care Improvement Project (SCIP) measures. Preprocedure verification process. After Surgery ACP anticipates end of procedure and gives proper types and doses of anesthetic agents. ACP goes with patient to PACU. Anesthetic Techniques and Agents ACP chooses anesthetic technique and agents in collaboration with the surgeon and patient. Contributing factors include patient’s current physical and mental status, age, allergies, pain history, and expertise of the ACP. Classification of Anesthesia Moderate to deep sedation. Procedures done outside the OR. May be administered by an RN under direct supervision of a physician. Must be administered by an ACP. May be necessary to change to general anesthesia during the procedure. Anesthesia Classification and Administration General Anesthesia IV induction agent: Involves rapid sleep and long enough for placement of LMA or ET tube. Inhalation agents: Volatile liquids or gases enter the body through alveoli, easy administration and rapid excretion. Adjuncts: Drugs added to the anesthetic regimen with synergistic or antagonistic effects. Dissociative anesthesia: Interrupts associative brain pathways while blocking sensory pathways. Opioids: Sedation and analgesia, induction and maintenance intraoperatively, pain management postoperatively. Benzodiazepines: Premedication for amnesia, induction of anesthesia, monitored anesthesia care. Neuromuscular blocking agents: Facilitate endotracheal intubation, relaxation/paralysis of skeletal muscles, interrupt transmission of nerve impulses at neuromuscular junction. Antiemetics: Prevent nausea and vomiting associated with anesthesia. Local anesthesia: Loss of sensation without loss of consciousness. Types: Topical, Ophthalmic, Nebulized, Injectable. Regional anesthesia (Block): Injection to a central nerve or group of nerves, used as preoperative analgesia, during surgery, and after surgery. Local and regional anesthesia: Little systemic absorption, rapid recovery, discharge with continued postoperative analgesia, no accompanying cognitive dysfunction. Methods of administration: Topical, local infiltration, regional nerve block. Anesthesia Administration Methods Spinal anesthesia: Injection of local anesthetic into CSF in the subarachnoid space, usually below the level of L2. Epidural block: Injection of local anesthetic into epidural space, does not enter CSF, but bonds to nerve roots as they enter and exit the spinal cord. Autonomic nervous system (ANS) blockade: Observation closely for signs of ANS blockade, such as bradycardia, hypotension, nausea, and vomiting. Anesthesia drugs need careful titration. Postoperative delirium: Common, communication difficulties, risk for injury from tape, electrodes, warming and cooling blankets, certain dressings. Osteoporosis or osteoarthritis: Risk for perioperative hypothermia. Anaphylactic reactions: Anesthetic agents, antibiotics, blood products, and latex may cause allergic reactions.  Malignant hyperthermia (MH): Rare disorder characterized by hyperthermia with skeletal muscle rigidity. Treatment: Prompt administration of Dantrolene (Dantrium, Ryanodex) to slow metabolism, reduce muscle contraction, and mediate catabolic processes. Prevention: Preventive measures include taking careful family history and teaching patients with MH to consider genetic testing. Preoperative nurse responsibilities: Verify patient’s understanding of surgery risks, ensure patient’s identity, prepare skin, perform preoperative assessment, monitor for ascending neurologic depression and unconsciousness, ensure immediate availability of airway equipment, emergency drugs, and monitors.