Transcript OR Experience - Faculty Sites

OR Experience
BY: Diana Blum RN MSN
Metro Community College
Statistics 2009
Total number of inpatient procedures
performed: 48.0 million

Cardiac catheterizations: 1.1 million
 Coronary artery bypass graft: 415,000
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Preoperative
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Begins with the scheduling of procedure
Ends at time of transfer to surgical suite
Places emphasis on safety and client
education
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The client’s readiness is critical to the outcome
Includes education and intervention to reduce
anxiety and complications, and to promote
cooperation
Communication and collaboration
with the surgical team is essential to
reach desired outcome
Procedures

Categorized by:
Reason for procedure
 Urgency of the procedure
 Degree of risk
 Anatomic location

GUIDELINES ON P.587
Types of Surgery
Cosmetic
 Palliative
 Reconstructive
 Elective
 Urgent
 Emergent
 Curative
 Exploratory
 Diagnostic
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Surgical Areas
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Preoperative holding area
Quiet, calm transition
 Equipment includes: 02, EKG machine, BP
cuff, code cart
 RN verifies that all relevant tests and
documentation are completed prior to surgery
 Abnormals reported to MD
 Confirm NPO status
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ASSESSMENT
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Preoperative health evaluation
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30 days before surgery, must be documented,
clears pt for surgery
Pre op history and physical exam
Done by anesthesia provider
 ASA classification, done with any type of
sedation (pg 589)
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Risk Factors
Elderly
 Obesity
 Diabetes
 Heart conditions
 Renal failure
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Assessment
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History
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Physical
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Provides a baseline for the client
Helps predict potential complications
Radiographic
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Looks at anxiety level, coping ability, and support system
Anxiety and fear may influence the amount and type of anesthesia and
affect ability to learn, cope, and cooperate
Laboratory
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important to obtain baseline assessment, complete vitals, report
abnormal findings to doctor
Psychosocial
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Age, drug/ETOH use, meds, alternative meds, medical hx, surgery hx,
anesthesia experiences, blood donations, allergies, family hx, type of
surgery planned, education recv’d about perioperative period, support
system
Provides baseline and looks at size & shape of heart and lungs
Diagnostics
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EKG- used as baseline. Looks for old MI, or other complications that
could postpone surgery
Question

Which diuretic can cause problems in
surgery?
A. lasix
 B. hydrochlorothiazide
 C. valium
 D. benadryl
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Lasix and hydrochlorothiazide may
cause excessive respiratory
depression resulting from an
associated electrolyte imbalance
Nursing Diagnosis
Disturbed sleep pattern r/t anxiety
 Ineffective coping r/t impending
surgery
 Anticipatory grieving r/t effects of
surgery
 Disturbed body image r/t anticipated
changes
 Powerlessness r/t health care
environment, loss of independence
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Education
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Doctor should explain purpose and expected
results of surgery
Consent needs to be obtained prior to surgery. (if
pt signs with an ‘X’ 2 witnesses must sign.
Client should ask questions if they don’t
understand a term or procedure
NPO requirements needs to be explained
Preoperative preparations need to be explained
(colon prep, or skin prep)
Client should understand post op exercises and
techniques prior to surgery—I.S., etc.
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Informed Consent
must be done prior to surgery
 Procedure, risks and benefits need to be
explained to the patient by the SURGEON
 The patient must be competent to understand
information
 Consent for blood
 Consent for anesthesia is separate
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Legal Responsibilities
DNR
 DNI
 Must be clearly documented
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Surgical Prep
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Bowel prep
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Skin prep-shower, hair removal (clippers)
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(see pg 610)
Preoperative meds
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Antibiotic
Tubes, drains, vascular access
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Pt must be educated prior to surgery
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Tubes
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Foley- monitors renal function
NG-used for abd surgery to decompress the stomach
Drains
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Reduces fear
Removes fluid for surgical site.
CT, JP, Hemovac, Orthopat
Vascular access
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For anesthesia
For drugs and fluids
Respiratory education
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Incentive spirometry
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Deep breathing
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Sit upright, feet firm on ground, gentle breath through
mouth, exhale gently
Expansion breathing
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Encourages clients to take deep breaths every 1-2 hours
after surgery
Usually 10x’s per hour or with each commercial break
from a TV show
Comfortable upright position, knees slightly bent, place
hands on each side just above waist
Splinting
use pillow or towel and place over surgical site, take 3
deep breaths and clear then cough to loosen secretions
See chart 18-4 for more thorough instruction
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DVT risk
Obese
 >40 yrs old
 Have cancer
 Immobile or decreased mobility
 Leg fracture or trauma
 History of DVT, PE, Varicose veins, or
edema
 Use oral contraceptives
 Smoke
 Decreased cardiac output
Get them antiembolism stockings
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Anxiety reduction
Distraction
 Promote rest
 Guided imagery
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Gerontological
Considerations
Go over instructions slower
 Have family present
 Co-existing disease increases risk
 Positioning
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Intra op
Nursing diagnosis
Risk for infection
 Impaired skin integrity
 Altered body temperature
 Anxiety
 Injury related to positioning and other
hazards
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Members
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Surgeon
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Surgical assistant (other doctor, surgical tech,
resident, intern)
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heads surgical team
Makes decisions related to surgical procedure
May need assistant
May hold retractors, suction wound, cut tissue, suture,
and dress wounds depending on scope of practice and
under supervision of physician
Anesthesia
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Anesthesiologist or Certified Registered Nurse
Anesthestist
Maintains airway
Monitoring circulation/respiratory status
Replace blood/fluid loss
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OR nurses
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Holding area nurse
Primary role is Circulating Nurse
Duties performed outside of sterile field
Scrub Nurse
Passes instruments, sponges in the sterile field
Perform surgical scrub
Very specialized role, most education is during
orientation, not in nursing school.
Surgical Areas
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Operating Room
Restricted area
 Trend towards less invasive procedures (less
scarring, quicker recovery, decreased length
of hospitalization
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Basic Guidelines for Surgical
Asepsis
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All materials in contact with the wound and within the
sterile field must be sterile.
Gowns are sterile in the front from chest to the level of the
sterile field, and sleeves from 2 inches above the elbow to
the cuff.
Only the top of a draped table is considered sterile.
Items are dispensed by strategically to maintain sterility.
Movements of the surgical team are from sterile to sterile
and from unsterile to sterile only.
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Movement around the sterile field must not cause
contamination of the field. At least a 1-foot
distance from the sterile field must be maintained.
Whenever a sterile barrier is breached, the area is
considered contaminated.
Every sterile field is constantly maintained and
monitored. Items of doubtful sterility are
considered unsterile.
Sterile fields are prepared as close as possible to
time of use.
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http://www.youtube.com/watch?v=E
vpcGmExsd4&feature=related
Question
true or false.
To maintain surgical asepsis, the nurse
knows that the sides and top of a
draped table is considered sterile.
Answer
False.
Rationale: Sterile drapes are used to
create a sterile field. Only the top
surface of a draped table is
considered sterile. During draping of
a table or patient, the sterile drape is
held well above the surface to be
covered and is positioned from front
to back.
Infection
Anyone with open wound, cold, or
any infection should not participate in
surgery
 Jewelry should be minimal
 Hands of surgical staff are usually
cultured every 3-6 months to
determine possible nosocomial
(hospital acquired) infections
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Attire
Time out procedure
Nurse asks pt to confirm procedure and is
verified with consent form
 Patient verifies the right site and surgeon
 2 patient identifiers
 Site mark
 “Time out”
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Name, procedure, site, document
 See pg. 612
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Anesthesia
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http://www.youtube.com/watch?v=W
OrjcLJ2IE0&NR=1
Anesthesia
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Def: induced state of partial or total loss of
sensation, occurring with or without loss of
consciousness.
Purpose: block nerve impulse transmission,
suppress reflexes, promote muscle
relaxation, and sometimes achieve
controlled level of unconsciousness
Choice depends on: type and duration of
procedure, area of body, safety issues,
emergency, pain management after
surgery, last meal or liquids or drugs
Types
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General—see slides
Local- Novocaine for example
Hypnosis
Cryothermia
Acupuncture
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TABLE ON PAGES 626-629
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General
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Definition: reversible loss of
consciousness induced by inhibiting
neuronal impulses in several areas of
the central nervous system
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Depress CNS
 Results
in analgesia (pain relief), amnesia
(memory loss), and unconsciousness with
loss of muscle tone and reflexes
Used in head, neck, upper torso and abd
surgeries
Stages of general
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1:sedation administered
 Induction and LOC, decreased sensation
 Warmth, dizziness, noises exaggerated
2: excitement/delirium
 LOC and relaxation, regular breathing
 Pupils dilate, HR increases, may need to restrain pt
 Do not touch pt
3: operative anesthesia
 Muscle relaxation, depressed vitals
 Unconscious, maintained for hours
4:danger = Medullary Depression
 Depressed vs, respiratory failure
 Too much anesthesia, cyanosis
Emergence: recovery from anesthesia
Types of general
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Inhalation: most controllable
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Fast acting
Passes through vaporizer
Depresses CNS
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Ex: Nitrous Oxide
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IV: rapid and pleasant
 Induce and maintain anesthesia
 Anesthetics
Opiods
 Etomidate
 Valium
Fentanyl
Morphine
 Versed
 Diprivan
Reversal agent for opoids=Narcan (0.2mg)
 Reversal agent for Benzos =
Romazicon(0.2mg)
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Muscle relaxants
Affect skeletal muscle
 Administered before intubation
 Assess with nerve stimulator
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Succinylcholine, Tracrium, Vecronium
 Reversal agent= Neostigmine (0.52mg
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Balanced: minimal disturbance to function,
used with elderly and high risk
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Regional (Spinal, Epidural, Peripheral
nerve block)~ gag and cough stay intact
 block transmission of sensory impulses
 Does not depress respirations
 Local injection of med
Types of Regional Anesthesia
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Spinal
Local anesthetic injected into subarachoid
space, directly into CSF
 “Blocks” at level of spinal cord (sensory and
motor)
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Epidural
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Local anesthetic into epidural space
Peripheral nerve block
Anesthesia of a certain area
 No systemic effect
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Complications of Regional
HA
 Hypotension
 Meningitis
 Hematoma at site
 Nerve damage
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Intraoperative Complications
Nausea and vomiting
 Anaphylaxis
 Hypoxia and respiratory complications
 Hypothermia
 Dysrhymias
 Malignant hyperthermia
 Disseminated intravascular
coagulation (DIC)
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Malignant Hyperthermia
Life threatening
 Predisposition is genetic
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causes increased calcium and potassium levels in skeletal
muscles
 Immediate reaction or several hours later
 s/s: tachycardia, dysrhythmias, muscle rigidity (jaw, face),
hypotension, tachypnea, mottling, cyanosis, myoglobournia
(muscle proteins in urine),
 *increase in CO2 and decrease sat
Care: stop agent, intubate, give dantrium to reverse, check
ABG, cooling techniques, monitor core temp, EKGs, insert foley,
hydrate, ICU for at least 24 hours
Chart 26-3
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Manifestations
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Hypoxia
Hyperthermia****THIS IS A LATE SIGN****
Dysrhythmias
Hypotension
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Early signs:
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contracture of jaw
Sinus tach
Increase in expiratory CO2
*Pg. 630 *
Complications continued
Overdose: can occur if metabolism
and drug elimination are slower (ht,
wt, and allergies are vital to know
before administration)
 Unrecognized hypoventilation: failure
to exchange gases can lead to cardiac
arrest, permanent brain damage, and
death. Vital to use end tidal carbon
dioxide monitor to confirm the
exchange
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Intubation complication
Broken or chipped teeth
 Swollen lip
 Vocal cord trauma
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Question
Malignant hyperthermia usually
manifests within what time frame
after induction of anesthesia?
a. 5 minutes
b. 10–20 minutes
c. 30 minutes
d. 45 minutes
Answer
10–20 minutes
Rationale: Malignant hyperthermia
usually manifests about 10 to 20
minutes after induction of anesthesia.
It can also occur during the first 24
hours after surgery.
b.
Local
Numbing agent is used
 Mentally alert
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Complications: potential cardiac
depression, toxic reaction, edema,
blurred vision, inflammation, etc. see
Types of local
Topical
 Infiltration: directly into wound or lesion
 Blocks:
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Field: injections around work site (lidocaine,
novocaine)
 Nerve: injection into or around nerve in involved
area-used for chronic pain relief
 Spinal: injection of agent into CSF in the
subarachnoid space-absorbed rapidly
 Epidural: placed in epidural space-may affect
breathing
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Moderate (Conscious)
Sedation
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Moderate (Conscious) sedation
Minimally depressed LOC
 Pt able to maintain airway
 Pt responds to physical and verbal stimuli
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Moderate (Conscious)
Sedation
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As a nurse, what do you need to have
available at the bedside?
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What medications might be given?
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What monitoring/assessments?
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What types of procedures?
Potential Adverse Effects of
Surgery and Anesthesia
Allergic reactions or drug toxicity
 Cardiac dysrhythmias
 Over sedation or Under sedation
 Trauma: laryngeal, oral, nerve, and
skin, including burns
 Hypotension
 Thrombosis
 See Chart 19-1
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Gerontologic Considerations
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Elderly patients are at increased risk for
complications because of:
 Pre-existing conditions.
 Aging heart and pulmonary systems.
 Decreased homeostatic mechanisms.
 Changes in responses to drugs because
of changes such as decreased renal
function, etc.
Nursing diagnosis
Risk for injury r/t positioning
 Impaired skin integrity r/t surgical
incision
 Risk for infection
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Important to remember
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Always know client’s
wishes about life sustaining
measures because they
apply in the OR as well
However some
facilities/doctors require
that the surgical client that
is DNR on unit is full code
in OR.
Always know the allergies
and reactions
Always know current lab
values because they could
postpone surgery
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Know the client’ s baseline
vitals to monitor for
complications
Patient identification
Correct informed consent
Verification of records of
health history and exam
Safety measures such as
grounding of equipment,
restraints, and not leaving
a sedated patient
Verification and
accessibility of blood
Positioning
Accommodates access
 Surgical view
 Maintain skin integrity (pressure ulcers)
 Injury to nerves may happen
 Prevent injury
 Complications:
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Compromised respiratory status, pressure
ulcers, injury to nerves
Surgical positions
Supine
 Trendelenburg
 Prone
 Lateral
 Jackknife
 lithotomy
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Bariatrics
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Deals with causes, prevention, and
treatment of obesity
First line: diet, exercise, behavior
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therapy, & antiobesity drugs
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BUT HAS ONLY SHORT TERM
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SUCCESS IN MANY CASES
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68
Antiobesity drugs:
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Orlistat (approved Feb ’07)
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- reduces absorption of fat by
inhibiting pancreatic lipase
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Metformin
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Byetta (delays gastric emptying)
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69
Bariatric Surgery
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Roux en Y: most commonly performed
- least likely to result in nutritional
deficiencies
- small bowel is divided & arranged
into a “y” and attached to the small
stomach pouch
- pt feels fullness rapidly after eating
70
Post op
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Starts at the completion of surgery
and transfer to PACU or ICU
Stabilize VS, maintain airway
 Prepare pt for discharge
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To work here in-depth knowledge of
the following areas needed: pharm,
pain management, and procedures,
good assessment skills, decision
maker in critical situations
Assessment
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Vitals are vital
 Usually q15” x4,
q30” x4, q1hr x4,
q2hr x4, then q4hr
Respiratory status
 Airway
management, lung
sounds, muscle use,
snoring, stridor
(high pitched
crowing)
Monitor PAIN
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Cardio
 Telemetry, ekgs, vitals, pulses, homans,
Neuro
 LOC, motor response, orientation, arousal
Fluid and electrolyte
 I/O, hydration, IVF, acid base
Renal
 Output, urine retention is common if no
foley
Gi
 N/V, peristalsis, monitor for ileus, NG tube
output if indicated
Skin
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Monitor wound, drainage, drains, dressings,
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Early infection can
be indicated on
increase in band
cells of the WBC
differential (left
shift)
Get culture
Notify MD
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Monitor ABGs and
CMP
Aldrete Post Anesthesia
Recovery Score (PARS)
Numerical scoring system to eval PACU
patients
 Based on activity, Respirations,
Circulation, Consciousness, O2 Sats
 Ranges from 0 to 10, 10 is the best
 Score when arrives in PACU, every 30 min
until 8 or higher is achieved
 Score also done at discharge
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Nursing diagnosis
Impaired Gas Exchange
Open airway
 Breathing pattern improved over baseline
 Adequate O2 saturation
 Provide supplemental oxygen
 Artificial airway if patient is minimally
responsive
 Cough deep breath, IS
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Risk for Imbalanced Fluid
Volume
Adequate hemostasis
 Normal fluid and electrolyte balance
 Monitor hourly for postop bleeding
 Mark drainage on dressing, monitor for
enlargement
 Monitor for possible drainage beneath patient
 Monitor for internal bleeding
 Monitor for signs of dehydration, fluid overload
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Risk for Decreased Cardiac
Output
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Rhythm, cardiac output
BP, heart rate consistent with baseline
Monitor for sinus tachycardia/bradycardia,
identify and treat cause
Monitor for hypotension; IV fluids, patient
positioning
Monitor for hypertension, identify and treat
cause
Risk for Imbalanced Body
Temperature: Hypothermia
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Normal core temperature
Monitor for core temperature <36°C (96.8°F),
shivering, patient report of feeling cold
Risk factors: patient history, length of surgery,
cold solutions
Blankets, clothing, ambient temp
Treat with active warming, meds
Pain
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Physiological and psychological effects
Delayed ambulation, diminished functioning
Monitor for pain management and respiratory
depression
PCA, PCEA: monitor for pain relief, untoward
effects
Monitor sensory level of the epidural
Anxiety
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Can increase morbidity and mortality, length of
stay
Affects VS, depresses immune system, delays
healing
Implicated in heart problems, postop pain
Individualized care plan based on patient
preferences
Frequent reassurance about condition and
progress
Maintain a calm, quiet, restful environment
Drains
see
chart
27-6
Hemovac
JP
Penrose
Chest tube
Types of wound healing
Post-Op Complications
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Evisceration
Dehiscence
SSI
Atelectasis
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Pneumonia
ileus
Urinary retention
DVT
Dehiscence
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Partial or complete separation of wound
layers
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Wound is open
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Prevention?
Evisceration
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Complete separation of wound layers
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Protrusion of internal organs
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Usually occurs 5-10 days post-op
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Prevention?
Surgical Site Infections
(SSI)
Aseptic technique
 Most infections are caused by exogenous
organisms
 Surgical wound classification (pg. 636)
 Risks:
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Obesity, smokers, malnourishment
Dehiscence
Evisceration
Complications
on chart 27-4
Atelectasis and Pneumonia
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Atelectasis
Collapse of alveoli
 Mucus accumulates
 Leads to fever and hypoxia
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Incidence of post op pneumonia 15%
 High fowlers
 IS, CDB
 Ambulate
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Gastrointestinal
N/V
 Flatus
 Bowel sounds
 Ileus-hypoactive bowel, delay in peristalsis
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Urinary Retention
Foley cath
 Must void within 6-8hrs
 Anesthesia causes relaxation, retention
 May have swelling from certain procedures
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DVT
LWM- Heparin or lovonox
 SCD
 TEDS
 Ambulation
 Leg exercises
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