Transcript The Intraoperative Patient

The Intraoperative Patient
By Lisa M. Dunn RN, MSN/ED, CCRN
Members of the Surgical Team
Surgeon
Surgical assistant
Anesthesiologist
Certified registered nurse anesthetist
Holding area nurse
Circulating nurse
Scrub nurse
Surgical technician/ Operating room technician
Environment of the Operating
Room
Preparation of the surgical suite and team safety
Layout
Health and hygiene of the surgical team
Surgical attire
Surgical scrub
Surgical Scrub, Gowning, and
Gloving
Anesthesia
Induced state of partial or total loss of sensation,
occurring with or without loss of consciousness.
Used to block nerve impulse transmissions, suppress
reflexes, promote muscle relaxation, and, in some
instances, achieve a controlled level of
unconsciousness.
General Anesthesia
Reversible loss of consciousness is induced by
inhibiting neuronal impulses in several areas of
the CNS.
State can be achieved by a single agent or a
combination of agents.
CNS is depressed, resulting in analgesia,
amnesia, and unconsciousness, with the loss of
muscle tone and reflexes.
Stages of General Anesthesia
Stage 1: analgesia
Stage 2: excitement
Stage 3: operative
Stage 4: danger
Administration of General
Anesthesia
Inhalation: intake and excretion of anesthetic gas or
vapor to the lungs through a mask
Intravenous injection: barbiturates, ketamine, and
propofol through the blood stream
Adjuncts to general anesthesia agents: hypnotics,
opioid analgesics, neuromuscular blocking agents
Balanced Anesthesia
Combination of intravenous drugs and
inhalation agents used to obtain specific
effects
Combination used to provide hypnosis,
amnesia, analgesia, muscle relaxation, and
reduced reflexes with minimal disturbance of
physiologic function.
Balance Anesthesia Continued…
Example:
-thiopental for induction
-nitrous oxide for amnesia
-morphine for analgesia
-pancuronium for muscle relaxation
Complications from General
Anesthesia
Malignant hyperthermia: possible treatment with
dantrolene
Overdose
Unrecognized hypoventilation
Complications of specific anesthetic agents
Complications of intubation
Question
In treating the client with malignant hyperthermia, the most
important intervention is:
A. Initiation of cooling measures
B. Administration of skeletal muscle relaxant
C. Reversal of anesthesia
D. Increasing rate of intravenous fluids
Local or Regional Anesthesia
Sensory nerve impulse transmission from a specific body
area of region is briefly disrupted
Motor function may be affected
Patient remains conscious and able to follow instructions
Gag and cough reflexes remain intact
Sedatives, opioid analgesics, or hypnotics are often used as
supplements to reduce anxiety.
Local Anesthesia
Topical anesthesia
Local infiltration
Regional anesthesia
-field block
-nerve block
-spinal anesthesia
-epidural anesthesia
Question
In reviewing preoperative teaching for a client scheduled to
have regional anesthesia, which statement by the client
indicates that additional teaching is needed?
A. “My legs may be numb for a while.”
B. “I hope I don’t get too nervous being awake.”
C. “It will be difficult to move my legs immediately after
surgery.”
D. “I am relieved that I will be asleep during this procedure.”
Complications of Local or Regional
Anesthesia
Anaphylaxis
Incorrect delivery technique
Systemic absorption
Overdosage
Complications of Local or Regional
Anesthesia continued….
Assess for CNS stimulation
Assess for CNS and cardiac depression
Assess for restlessness, excitement
Assess for incoherent speech
Assess for headache, blurred vision
Assess for nausea/vomiting, metallic taste
Assess for tremors and/or seizures
Assess vital signs against base line vital signs
Surgical Fires
Goal 11:
Reduce the risk of surgical fires
NPSG.11.01.01: The organization educates staff, including
licensed independent practitioners who are involved with
surgical procedures and anesthesia providers, on how to
control heat sources, how to manage fuels while maintaining
enough time for patient preparation, and establish guidelines
to minimize oxygen concentration under drapes.
2005 Thyroid Surgery. Patient had
12 reconstruction surgeries
Growing use of electrosurgical devices and paper hospital
drapes have contributed to fires in the operating room.
“affecting between 550 and 650 patients a year,
including 20 to 30 who suffer serious, disfiguring
burns. Every year, one or two people die this way”
(MSNBC, 2006).
Question
An operating room nurse is positioning a client on the
operating room table to prevent the client’s
extremities from dangling over the sides of the table.
A nursing student who is observing for the day asks
the nurse why this is so important. The nurse
responds that this is done primarily to prevent:
A. An increase in pulse rate
B. A drop in blood pressure
C. Nerve and muscle damage
D. Muscle fatigue in the extremities
Question
A nurse is preparing a preoperative client for transfer to the
operating room. The nurse should take which action in the
care of this client at this time?
A. Ensure that the client has voided
B. Administer all the daily medications
C. Practice postoperative breathing exercises
D. Verify that the client has not eaten for the last 24 hours
Treatment of Complications
Establish an open airway
Give oxygen
Notify the surgeon
Fast-acting barbiturate is usual treatment
If toxic reaction is untreated, unconsciousness,
hypotension, apnea, cardiac arrest, and death may result.
Conscious Sedation
IV delivery of sedative, hypnotic, and opioid drugs
reduce the level of consciousness but allows the patient to
maintain a patent airway and to respond to verbal
commands.
Diazepam, midazolam, meperidine, fentanyl, alfentanil,
and morphine sulfate are the most commonly used drugs.
Conscious Sedation Continued…
Nursing Assessment Includes:
-Airway
-Oxygen saturation
-Level of consciousness
-Electrocardiographic status
-vital signs monitor every 15 to 30 minutes
Collaborative Management
Assessment
Medical record review
Allergies and previous reactions to anesthesia or
transfusions
Autologous blood transfusion
Laboratory and diagnostic test results
Medical history and physical examination findings
Question
A nurse is conducting preoperative teaching with a client
about the use of an incentive spirometer. The nurse should
include which piece of information in discussions with the
client?
A. Inhale as rapidly as possible.
B. Keep a loose seal between the lips and the mouthpiece.
C. After maximum inspiration, hold your breath for 15
seconds and exhale.
D. The best results are achieved when sitting up or with the
head of the bed elevated 45 to 90 degrees.
Risk for Perioperative Positioning
Injury
Interventions include:

Proper body position

Risk for pressure ulcer formation

Prevention of obstruction of circulation, respiration,
and nerve conduction
Impaired Skin Integrity
Interventions include:
-plastic adhesive drape
-skin closures include sutures (absorbable and
nonabsorbable), staples, and dermabond, retention
sutures
-insertion of drains
-applications of dressings
-transfer of a patient from the operating room table to
the stretcher or bed
Special Drains
•Remove pus
•Remove blood
•Remove other body fluids from wound
•Does not result in faster wound healing or prevent
infection.
Penrose Drain
Jackson Pratt or JP
Hemovac
Dressings
Dry or moist
Gauze
Hydrocolloid
Protects the wound from surface contamination
Hydrogel
Maintains a moist surface to support healing
Wound V.A.C.
Uses negative pressure to support healing
Dressings continued.
Changing
Know type of dressing, placement of drains, and equipment
needed.
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently cleanse the wound.
Administer analgesics before dressing change.
Montgomery Straps
Ace wraps
•To reduce the swelling of an injured area of the body
•To hold wound bandages in place
•To wrap around a arm or leg splint during healing
•To improve blood flow to a limb like an arm or leg
•To hold cold or hot packs in place on a body part
Ice pack
•A general rule of thumb is to ice an injury over a period of
24 to 72 hours.
•Apply cold packs for periods of up to 20 minutes every two
to four hours.
•When your skin starts to feel numb, it's time to give your
body a break from a cold pack.
Question
Which of the nursing interventions would the nurse
implement for the older client to minimize skin
breakdown related to surgical positioning?
A. Padding bony prominences
B. Taping joints in anatomic position
C. Monitoring for excessive blood loss
D. Applying elastic stockings to lower extremities
Potential for Hypoventilation
Continuous monitoring of:
-breathing
-circulation
-cardiac rhythms
-blood pressure and heart rate
Continuous presence of an anesthesia provider
Question
A postoperative client asks a nurse why it is so important to
deep-breathe and cough after surgery. In formulating a
response, the nurse incorporates the understanding that
retained pulmonary secretions in a postoperative client can
lead to:
A. pneumonia
B. fluid imbalance
C. pulmonary edema
D. Carbon dioxide retention
Question
A client with a perforated gastric ulcer is scheduled for surgery. The client
cannot sign the operative consent form because of sedation from opioid
analgesics that have been administered. The nurse should take which
appropriate action in the care of this client?
A. Obtain a court order for the surgery
B. Send the client to surgery without the consent form being signed.
C. Have the hospital chaplain sign the informed consent immediately.
D. Obtain a telephone consent from a family member, following hospital
policy.