Week 2 - PP4.pdf

Week 2: Lecture overview Week 1 introduced the perioperative journey, which includes three phases: 1. Preoperative (last week) 2. Intraoperative (this week) 3. Postoperative (next week) focus on the intraoperative phase, considers: Nursing roles and car...

Week 2: Lecture overview Week 1 introduced the perioperative journey, which includes three phases: 1. Preoperative (last week) 2. Intraoperative (this week) 3. Postoperative (next week) focus on the intraoperative phase, considers: Nursing roles and care. Anaesthesia concepts. Airway management. Upper airway disruptions. First, we will briefly revisit premedications from the preoperative phase. Perioperative nursing and roles: ACORN 4 https://www.acorn.org.au/perioperative-nursing Lecture Week 2 | NURS2040 - Professional Practice 4  Purpose of preoperative medications Drugs used prior to the administration of an anaesthetic agent to facilitate a safe anaesthetic Depending on patient circumstances and prescription, premedications may be used to: Provide analgesia. Prevent nausea & vomiting. Promote sedation & amnesia. Decrease anaesthetic requirements. Facilitate induction of anaesthesia. Relieve apprehension & anxiety. Prevent autonomic reflex response (e.g sweating, and urination). Decrease respiratory and gastrointestinal secretions. Lecture Week 2 | NURS2040 - Professional Practice 4 Pre-operative medications Less common Either IM, IV, intranasally or PO (oral usually preferred) Before premed given, LAST MINUTE QUESTIONS, consent forms verified Usually given 30-90 minutes before surgery OR IV in holding bay or in the OT. Paediatrics or needle phobias emla cream local anaesthetic (lignocaine & Prilocaine) Clinical application/critical thinking- how would you manage the following situation? You are caring for an 18-year-old patient who has come into hospital for a surgical procedure and has a known needle phobia. The patient asked if they can apply Emla cream in advance (numbing cream) and you informed the patient that this will be okay. You report back to the wait for the cream to work (it usually takes 45minutes-1hr). You accompany the nurse who hurries back into the room, and you witness see that the patient is visibly distressed at this decision.  Augmented Reality (AR) advances in preoperative planning- using the Overview of intraoperative nursing care https://www.medivis.com/surgical-ar Holding bay: Identify the patient using identifiers. Verify the surgical site, surgical procedure, consent and patient understanding of the procedure. Assess level of consciousness (GCS), assess Integumentary system and review medical records. During surgery: Maintain safety and integrity of the sterile field, ensures correct counts of surgical equipment, correct positioning of patient to prevent Hospital Acquired Pressure Injuries (HAPI), ensure safety regarding electrical equipment / lasers, medications safely administered, monitor patient for any deterioration in vital signs, monitor FBC and any excessive loss, provide touch and reassurance to the patient prior to a general anesthesia, or if spinal/ epidural consistently reassures patient. Communicates with the MDT of any variances and intervenes promptly to prevent complications. Completion: As procedure nears completion, inhaled anaesthetic agents ceased and reversal agents administered if muscle relaxants have been used. Pre-reading: Post anesthesia: assess GCS, vital signs (compare to preop vitals and assess Ch 38-pp 968-975 for deterioration), safely administer medication, monitor airway, breathing and circulation, complete comprehensive medical & nursing clinical report ready for transfer to PARU. Lecture Week 2 | NURS2040 - Professional Practice 4 Sentinel events and safety Lecture Week 2 | NURS2040 - Professional Practice 4 https://www.safetyandquality.gov.au/our-work/indicators-measurement- and-reporting/incident-management-and-sentinel-events  Overview of perioperative personnel Nursing: Anaesthetic nurse/technician Circulating/scout nurse. Other roles: Instrument/scrub nurse. Surgeon and surgical assistant Post anaesthesia care unit (PACU) nurse. Anaesthetist Floor/shift coordinator; SDN; NUM Pharmacist Perioperative surgical nurse assistant (PSNA). Perfusionist-cardiac bypass Advanced roles: Nurse Practitioner; Nurse machine endoscopist; Nurse Cystoscopist; Cosmetic Nurse. Orderly/PCA ACORN periop nursing roles: Orthopaedic technician https://www.acorn.org.au/index.cfm?display=785510 Radiographer CSSD staff cleaning, checking, packing, sterilising Support staff-clerical, cleaning Product representatives Lecture Week 2 | NURS2040 - Professional Practice 4  Positions during the procedure Surgical Assistant Circulating Imaging Nurse tower 1 Instrument Nurse Suction Anaesthetic Anaesthetist machine Diathermy Anaesthetic Nurse Imaging tower 2 Surgeon Surgical Assistant (if needed) VR in labs/simulation tutorials-samples of roles and positioning of staff in live surgeries Lecture Week 2 | NURS2040 - Professional Practice 4  Anaesthetic Nurse Participate in patient identification and other processes outlined in the Safety Advocate for the patient. Collaborate with and assist the anaesthetist. Anticipate and provide equipment and Understands, prepares and assists in any supplies. anaesthetic emergencies. Prepares and checks the anaesthetic Monitors airway devices, ETT cuff machine, equipment, IV and arterial lines as measurements, invasive pressures and all required. other equipment relating to patient Assist in maintaining patient airway. observations. Applies monitoring devices. Measures and documents blood, fluid and other loses in the patients fluid balance chart. Assists with patient transfer before and after surgery. Collaborates with post-anaesthesia care unit staff. Overview of nursing roles https://www.acorn.org.au/nursing-roles Lecture Week 2 | NURS2040 - Professional Practice 4 Circulating Nurse (Scout Nurse) Participates in processes outlined in the surgical safety checklist. Advocates for the patient. Assists to prepare the room ensuring that all supplies and equipment are available. Anticipates the needs of the surgical team before and during surgery. Monitors the draping procedure and the intraoperative environment for breaches in aseptic technique and initiates corrective Ensures correct handling and labelling of action. surgically removed human tissue and Prepares, records, labels and sends blood explanted items. pathology. Performs and documents the surgical count with the instrument nurse. Documents intraoperative nursing care and medications used by the operative team and patient outcomes. Lecture Week 2 | NURS2040 - Professional Practice 4 Instrument Nurse (Scrub Nurse) Participates in the process outlined in the surgical safety checklist Advocates for the patient Prepares instrument table and organises sterile equipment in a functional manner for surgery Anticipates needs of the surgical team prior to & during surgery Assists with skin prep and draping of the surgical site Works directly with surgical team Passes equipment to the surgeon and Adheres to, and maintains, surgical aseptic assistants by anticipating their needs technique throughout the procedure Performs surgical count with the circulating Monitors breaches in surgical aseptic nurse technique & initiate corrective action Ensures correct handling and labelling of surgically removed human tissue and explanted items Documents intraoperative nursing care & patient outcomes. Lecture Week 2 | NURS2040 - Professional Practice 4  THE RECOVERY ROOM NURSE PACU / PARU s airway, breathing and circulation Pain control Relief from nausea and vomiting Assessment of the wound site Management of fluid balance Documentation  Types of anaesthesia: General (GA) Anaesthetics are classified as general or regional. General (GA)= Loss of all sensation and consciousness The 3 PHASES of GA: All protective airway reflexes of cough, swallow and gag are suppressed INDUCTION : begins with administering of Acts by blocking the awareness center in reticular activating system (RAS) in brain so amnesia, analgesia, anaesthetic agents until pt ready for positioning hypnosis (artificial sleep), and relaxation occurs or surgical prepping -INTUBATION Administered via IV, inhalation of gases with facemask, or through laryngeal mask (LMA) or endotracheal tube (ETT) MAINTENANCE : until near completion of the procedure Benefits: EMERGENCE : starts as the pt begins to Suppression of physiological and emotional stress of surgery and feeling of pain emerge and ends when pt ready to leave the OT. EXTUBATION GA can be adjusted for length of surgery, titrated for age and physical status Disadvantages: Recovery from anaesthesia can be considered a 4th phase of GA. Close monitoring of neurological, respiratory, and cardiac functions when patient is unconscious as it depresses these systems Patients often more nervous about GA than surgery due to loss of control IV technique example: Induction agent propofol with 30% to 40% O2 and Nitrous oxide (N2O) Amnesic drug such as midazolam Analgesic such as fentanyl or morphine sulfate Pre-reading: A muscle relaxant (causes temporary paralysis) such as Ch 38-pp 968-975 rocuronium Lecture Week 2 | NURS2040 - Professional Practice 4  Types of anaesthesia: Regional anaesthesia Regional analgesia=temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body. The person loses sensation and movement in a targeted area of the body but remains conscious. Topical (surface) anaesthesia (next slide)-applied directly to skin and mucous membranes Local anaesthesia (LA) (next slide)-injection of local anaesthetic into specific area e.g. sutures, obtaining biopsy, removing lesion- minor surgical procedures Peripheral nerve blocks Intravenous Block (Bier block) Central nerve blocks (epidurals and spinal) Conscious sedation can be used alone or with regional anaesthesia for some tests and procedures person remains awake, with patent airway e.g. midazolam for sedation, with an analgesic like fentanyl/morphine. Procedure examples- endoscopes, and some angioplasties. Lecture Week 2 | NURS2040 - Professional Practice 4  Types of local anaesthetics What is it? Local anaesthetics are drugs that block conduction when applied locally to nerve tissue. The block produced is reversible. Mechanism of action of local anesthetics- https://www.youtube.com/watch?v=6-vrOjICrfU How does it work? Interrupts the generation of nerve impulses by altering the flow of sodium into nerve cells through cell membranes. Some can be topical (surface application) e.g. aerosols or spray (co- phenylcaine forte spray), nebuliser, gels, ointments (EMLA) Lignocaine quick/short acting. Bupivacaine slow and long acting. Ropivacaine slow and long acting. Amethocaine topical. Prilocaine intravenous. Lecture Week 2 | NURS2040 - Professional Practice 4 17 Regional anaesthesia Peripheral nerve blocks where the (LA) is injected into the vicinity of a nerve trunk or group that supplies sensation to a small area of the body (e.g. Large= brachial plexus block, pudendal block for obstetric surgery; & Small = single nerve e.g. facial nerve Peripheral nerve block demo for hand procedure-Youtube: https://www.youtube.com/watch?v=NThhhrdhC84 Intravenous is used most often for procedures involving the arm, wrist and hand. An occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected IV agent beyond the involved extremity, and the duration of surgery is time critical because an occlusive tourniquet is in place. -YouTube: https://www.youtube.com/watch?v=5NuFVN5x1TA Central nerve blocks (e.g. spinal or epidural) the local anaesthetic (LA) is injected into spinal roots where they emerge from the spinal canal. Spinal blocks involve LA into the subarachnoid space, whilst epidural anaesthesia involve LA and/or opioid to epidural space (outside dura mater) Epidural, spinal, and combined spinal-epidural overview-Youtube: https://www.youtube.com/watch?v=DtzI5bX7NyA  Nursing management for local and regional anaesthetic (More detail on pain management and management of spinal/epidurals covered in week 4) Obtain history of prior anaesthetics and outcomes. Check fasting status- some patients may require fasting if they are high risk of being converted to GA. Monitor vital signs. Observe for signs of autonomic nervous system blockage e.g. hypotension, bradycardia, nausea and vomiting and report. Monitor and report for systemic absorption or toxicity block is - pt may experience tingling in arms and hands, dyspnoea or apnoea. Supervise ambulation post epidural and spinal anaesthesia. Dermatomes Lecture Week 2 | NURS2040 - Professional Practice 4  Airway management and considerations Revise anatomy of the airway for use and management of artificial airways When patient is unconscious- muscle tone of upper airway is lost, causing tongue and epiglottis to fall back on the posterior wall of pharynx obstructing the airway Review of anatomy for intubation: Artificial airways e.g. guedels (oropharyngeal airway) helps https://www.youtube.com/watch?v= prevent airway obstruction; nasopharyngeal airways can be used SUOAnZLO2Os for oral/dental procedures- requires lubricant and inserted through nose Chin lift and jaw thrust also required, often with airway adjuncts Nurse must be familiar with managing airway, with artificial airway options and for troubleshooting.. grip (hand) when holding face mask insitu to ensure patent airway and adequate seal (see readings) Bask mask ventilation video: https://www.youtube.com/w atch?v=KqgT_mtdF04 The following slides are based on the text below Ch.8 pg 253-299 https://findit.library.nd.edu.au/permalink/61UON DA_INST/188c8qt/alma991001554630006416 PREOPERATIVE AIRWAY ASSESSMENT page 255 https://findit.library.nd.edu.au/permalink/61UON DA_INST/188c8qt/alma991001554630006416 AIRWAY EQUIPMENT 1. Laryngoscope handle 2. Curved laryngoscope blade 3. Straight laryngoscope blade 4. Endotracheal tube (ETT). 5. Stylet a probe that assists with intubation 6. Large oral airway (guedels) 7. Small oral airway (guedels) 8. Naso pharyngeal airway 9. Yankauer sucker 10.McGill Forceps aid passage of endotracheal tubes 11.Face mask-sized for patient 12.10 ml Syringe 13.Carbon dioxide detector / filter 14.Tracheal light 15.Airway Bougie similar in function to a stylet but more elastic 16.Laryngeal mask airway (LMA) or supraglottic airway device 17 17. Ambu bag or bag valve mask 16 (BVM) (See p. 267 of text) ANAESTHETIC INDUCTION Pt becomes apnoeic Eyelash reflex gone-eyes taped shut Airway is checked for patency by ventilating the patient with a mask. Position head or insertion of an oral/nasal airway used to maintain a patent airway.  adjunct airway For the following slides: Prereading- Airway/tracheostomy care Ch53. pg1466- 1484 Guedels airway Video: https://oxfordmedicaleducation.com/clinical- skills/procedures/oropharyngeal-airway/ Nasopharyngeal airway video: https://oxfordmedicaleducation.com/clinical- skills/procedures/nasopharyngeal-airway/ LARYNGEAL MASK AIRWAY (LMA) definitive airway Intubation with LMA: May be inserted without a muscle relaxant Minimises aspiration risk Short procedure use-not suitable for all patients Surgical site not in head or neck area Inserted in mouth, positioned over the larynx and inflated-no need to visualise vocal cords Video: https://oxfordmedicaleducation.com/clinical- skills/procedures/supraglottic-airway/ LARYNGOSCOPES Used for performing ETT intubations. A laryngoscope consists of a blade, of varying sizes (1 to 4), which includes a fibreoptic light source, and a handle, which contains the power source for the light. For most laryngoscopes the blade is curved. For small babies -straight blade. INTUBATION ENDOTRACHEAL TUBE definitive airway AIM Facilitate ventilation and prevent aspiration Different sizes available For most women, a 7.5mm ETT will suffice, and a size 8.0 8.5 for most men. The can The 7.5mm ETT works well for most ETT through the vocal patients cords for patients with Benefits: difficult airway see link Maintenance of a clear airway under with video: https://litfl.com/bougie/ difficult circumstances Operations on the head, neck, mouth, throat and nose Protection of the trachea Facilitation of tracheobronchial toilet Controlled ventilation  INSERTION - ETT Posture: Sniffing the air Neck flexed Head extended (straight line) Inflate airway cuff to completely occlude the trachea (ensures air delivered enters lungs and not oesophagus) Airway cuff manometer used to inflate cuff to correct cmH20 pressure (10ml syringe can be used until manometer is available) ENSURING THE RIGHT PLACEMENT OF ETT Listen for bilateral breath sounds Observing uniform bilateral chest movement etCO2 trace (capnography) Cuff inflated Tube secured making note of cm marking on ETT to lips e.g. 22cm at lips, R side of mouth Insertion Video: https://oxfordmedicaleducation.com/clinical- skills/procedures/endotracheal-tube/ RAPID SEQUENCE INDUCTION CRICOID PRESSURE (Sellick s Maneuvre) Performed to reduce the risk of pulmonary aspiration of acid stomach Cricoid cartilage of the larynx contents Digital pressure applied to cartilage Oesophagus compressed by posterior Indications for RSI cricoid cartilage and vertebra (C6) Unknown fasting time Prevents regurgitation and aspiration Pregnancy (closes oesophagus which lies behind it) Hiatus hernia Released when ETT cuff is inflated and Bowel obstruction only when asked to do so GI bleeding Gastric reflux Trauma sustained after eating  Airway obstructions and complications- medical emergencies Obstructive Sleep Apnoea (OSA)-post op PACU- patient may need own device post op (CPAP) Aspiration- Decreased throat reflexes under GA; Acidic gastric contents enter the lungs; Residual effects impede lung function and gaseous exchange; Oedema, alveoli collapse, hypoxia Tracheostomy formation and care Acute airway obstruction is a medical emergency-insertion of a tracheostomy or similar airway may be required Tracheostomy a surgically created stoma (opening) in the trachea, performed to establish an airway: Bypassing an upper airway obstruction. Facilitating secretion removal. Allowing for long-term mechanical ventilation. Insertion of tracheostomy video: https://oxfordmedicaleducation.com/clinical- Pre-reading skills/procedures/tracheostomy/ for lab: Suctioning a tracheostomy: Suctioning https://www.youtube.com/watch?v=lGpfuHdrUgk airway Ch 62 Lecture Week 2 | NURS2040 - Professional Practice 4  Catastrophic events in the operating theatre Anaphylactic reactions Malignant hyperthermia Manifestation may be masked by Muscle rigidity. anaesthesia. Tachycardia. Vigilance and rapid intervention are essential. Tachypnoea. Symptoms include hypotension, tachycardia, Elevated body temperature - 41 C or higher bronchospasm and pulmonary oedema. (NOT an early sign). Antibiotics and latex main instigators. Respiratory & metabolic acidosis. Ventricular arrhythmias. Can result in cardiac arrest and death. Situational Awareness (SA) importance: refers to the way in which people collect (perceive), interpret (comprehend) and use information to inform decision making - (projection). essential video to watch for periop! In a healthcare environment, nurturing this skill can help to prevent errors and improve patient outcomes. https://www.youtube.com/watch?v=usVus Individual and contextual factors, such as skill, fatigue, distractions, 9ia-q0 equipment design, team factors and cognitive biases, can affect Gluyas, H., & Harris, S. (2016). Understanding situation awareness and its importance in patient safety. Nursing Standard (Royal College of Nursing (Great Britain) : 1987), 30(34), 50-60. doi:10.7748/ns.30.34.50.s47 Lecture Week 2 | NURS2040 - Professional Practice 4 Based on what you know now from the previous slides, what is