Transcript General Anesthetics

Intraoperative Nursing
Introduction
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Today’s class:
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The OR environment
Safety in the OR
Nursing measures
Medications & effect on patients
Intraoperative Phase
Major nursing goal: help the patient
make it through surgery without injury
 A team effort
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Surgical Team
MEMBERS OF THE SURGICAL
TEAM:
Patient
 Holding Area Nurse
 Circulating nurse
 Scrub role
 Surgeon
 Registered nurse first assistant
 Anesthesiologist, anesthetist
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Patient
Holding Area Nurses
Patient waits here until OR
 Greet patient
 Review medical record/pre-op checklist
 Verify consent forms are signed
 Document risk assessment
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Assesses physical/emotional status
 Gives emotional support
 Answers questions
 Provides extra education PRN
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Marking Patient prior to surgery
Circulating Nurse
RN
 Manager of that OR suite
 Sets up the room – supplies, blood
products, etc.
 Gathers and inspects all equipment
 Prepares the OR bed
 Meets, greets, identifies patient
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Transfers Pt to OR bed, positions
 Monitors aseptic technique and watches
for breaks
 Greets patient, assists with positioning
 Coordinates xray, lab
 Assists anesthesiologist as he/she
induces patient
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Assists with documentation including:
– Count of all sponges, sharps, and
instruments
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Notifies PACU of arrival time and any
special needs
Scrub Role
RN,LPN, OR technician, Certified
Surgical Technologist (CST)
 Sets up sterile field
 Drapes patient
 Hands sterile instruments, sponges,
sutures, etc., to surgeon
 Aids in gowning and gloving
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Assists with sponge, needle, and
instrument counts
 Observes team for breaks in aseptic
technique
 This role also done by:
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– Operating room technicians (ORT’s)
– Certified Surgical technologists (CST’s)
Surgeon and Surgical Assistants
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Surgeon
– Heads the surgical
team
– Makes major
decisions
– Performs surgery
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Surgical assistants
– intern, resident, med student, another MD,
PA, CRNFA, or surgical technologist
– Help expose operative site
» Hold retractors
» Suction wound
» Cut tissue
» Suture
» Dress wounds
RN First Assistant
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Assist surgeon
Anesthesia Providers
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Anesthesiologist:
– MD who specializes in giving anesthetic
agents
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Certified Registered Nurse Anesthetist
CRNA:
– RN who has graduated from accredited
nurse anesthesia program
– Supervised by anesthesiologist, surgeon,
dentist, or podiatrist
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Duties:
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Administers anesthesia
Evaluates patient pre-operatively
Keeps patient alive during surgery!
Alerts surgeon to any problems
Monitors VS, I & O, cardiopulmonary
function
OR Nursing Staff
PHYSICAL ENVIRONMENT
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Pre-op Holding
Area
– Pt waits in here until
surgery
– IV started,
assessment
– In some hospitals,
family can stay with
pt until time to go to
OR
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Operating Room
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Environmentally controlled
Temperature 68 - 75 degrees
Restrict # of people
Wear special clothes, booties, cap, etc.
Room cleaned inbetween cases with
detergent germicide
Operating Room
Minimally Invasive and Robotic
Surgery
Health Hazards Associated with
the Surgical Environment
Exposure to blood/body fluids
 Lazer risk
 Exposure to latex, radiation, toxic
agents
 Potential for Infection
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Prevention of Infection
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Surgical environment
– Unrestricted zone
– Semirestricted zone
– Restricted zone
Surgical asepsis
 Environmental controls
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Surgical Asepsis
Surgical Scrub, Gowning, and
Gloving
Nursing Management in the
Operating Room
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Provide emotional care
– Greet patient at door; help patient to feel
safe and secure
– If awake during surgery -> support,
explain and reassure patient
– During initial stage of anesthesia, stand at
bedside, touch shoulder, hold hand, etc.
Provide Safety
surgical asepsis
 send correct speciman
 correct sponge count
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Assist with Surgical Positions
Prevent Perioperative
Positioning Injury
Interventions include:
 Proper body position
 Pad bed with foam or silicone gel pads
 Properly place grounding pad
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Prevent obstruction of:
– circulation,
– respiration, and
– nerve conduction
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Good access to surgical site
Prevent infection of wound
Assess patient for risk
 Do skin prep
 Maintain sterile technique
 Use of Plastic adhesive drapes
 Skin closures, sutures and staples,
nonabsorbable sutures
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Common Skin Closures
Insertion of drains
 Application of dressing
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Prevent Hypoventilation
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Continuous monitoring (every 5
minutes) of:
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Breathing
Circulation
Cardiac rhythms
Blood pressure and heart rate
Continuous presence of an anesthesia
provider
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Prevent client heat loss
– apply warming blanket after surgery
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Transfer patient from the operating
room table to a stretcher
ADMINISTRATION OF
ANESTHETICS
Anesthetics
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Agents that depress the central nervous
system (CNS)
– Depress consciousness
– Lose ability to respond to sensory
stimulation (including pain)
– Muscle relaxation
Classifications
General anesthesia
 Local anesthesia
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GENERAL ANESTHESIA
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Administering a combination of several
different drugs to achieve the following
goals:
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Analgesia (loss of pain perception)
Unconsciousness
Amnesia
Block the body’s reflexes
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Ideal result:
– Best effects with the fewest adverse effects.
Four Stages of General
Anesthesia
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Stage 1—analgesia stage
– No pain but still awake
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Stage 2—excitement stage
– Excitement, often combative
– Many signs of sympathetic stimulation
(tachycardia, ↑ RR, BP changes)
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Stage 3—surgical anesthesia stage
– Skeletal muscles relax, RR becomes
regular, progressive loss of eye reflexes,
pupils dilate
– Can do surgery in this stage
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Stage 4—medullary paralysis
– Danger! CNS depression; patient can die
Also 3 phases:
Induction – from beginning of
anesthesia to Stage 3
 Maintenance – stage 3  completion
 Recovery – DC of anesthesia until
patient has awakened and
communicated
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Administration of General
Anesthesia
Inhalation
 IV injection
 Balanced anesthesia
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– Combination of IV drugs and inhalation
agents used to obtain specific effects
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One Example:
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thiopental for induction,
nitrous oxide for amnesia,
morphine for analgesia, and
pancuronium for muscle relaxation
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Adjuncts to general anesthetic agents:
– hypnotics, opioid analgesics,
neuromuscular blocking agents
Handout
Inhalation Agents
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Volatile liquids or gases that are:
– Vaporized in oxygen
– Inhaled to induce anesthesia
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Advantages:
– Easy to administer
– Can rapidly excrete by ventilation
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Disadvantage:
– May irritate lungs, cause coughing
Inhalation Agents - volatile
liquids
Inhaled Gases (“carrier” gases)
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Nitrous Oxide - “laughing gas”
– most widely used
– used to deliver inhalation agent to patient’s
lungs
– Helps to increase effectiveness of volatile
liquids so less is needed
Intravenous Anesthetics
Sedative-hypnotics
Barbiturates
 Benzodiazepines
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Barbiturates
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Two most frequently used barbiturates
used:
– thiopental (Pentothal)
– methohexital (Brevital)
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How barbiturates work:
– Increase cell’s affinity for GABA, a
neurotrnsmitter that brings us peace and
tranquility
GABA quiets cell firing.
GABA
Neuron
Benzodiazepines
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Most commonly used:
– Midazolam (Versed)
– diazepam (Valium)
cause amnesia
 decrease anxiety
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Neuromuscular Blocking Agents
(NMBA)
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Block transmission of nerve impulses - create
muscle relaxation
Used to maintain controlled ventilation
during surgery
Succinylcholine
– Paralyzes quickly, is gone quickly (four - eight
minutes)
– For ET intubation
– Causes complete respiratory paralysis
– Does not cause sedation, does not relieve pain!
Antiemetics
Prevent and treat nausea and vomiting
(most common side effect of anesthesia)
 Examples:
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– droperidol (Inapsine)
– metoclopramide (Reglan)
GENERAL MECHANISM OF
ACTION OF INHALED & IV
ANESTHETICS
Easily cross blood-brain barrier
 Concentrate in nerve cell membranes
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Overall effect: orderly and systematic
reduction of sensory & motor CNS
functions
 Therapeutic doses: minimal depression
of vital functions
 Overdose: death due to circulatory &
respiratory failure
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Side Effects & Adverse Effects
Not as many as in the past
 Dose dependant
 Vary with each drug
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Most common side effects
Myocardial depression
 Respiratory depression
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Complications from General
Anesthesia
Malignant hyperthermia
 Overdose
 Unrecognized hypoventilation
 Complications of specific anesthetic
agents
 Complications of intubation
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Malignant Hyperthermia
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Cause:
– inherited defect of skeletal muscle;
stimulated by muscle relaxants or
anesthetic agent.
– Calcium (inside the cells) increases causing
increased metabolic rate
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Signs and symptoms:
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Tachycardia (150)
increased temperature (105)
muscle rigidity
end stage is cardiac arrhythmias, vascular
collapse, death
Mortality rate: 50%
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Treatment
– First - STOP the anesthetic agents and give
100% oxygen
– Give Dantrolene IV (to block release of
calcium)
– Cool the body slowly - ice packs, chilled IV
or irrigation fluids, cold sponge bath
– Foley
– IV drugs - Na Bicarb
– Monitor and treat arrhythmias (Lidocaine)
May occur 10-20 minutes after
induction, or up to 48 hours after OR.
May recur up to 3 days after the first
episode.
 Important to get good history prior to
OR
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Local Anesthesia
Briefly disrupts sensory nerve impulse
transmission from a specific body area
or region
 Delivered topically and by local
infiltration
 Patient remains conscious and able to
follow instructions
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Regional Anesthesia
Type of local anesthesia
 Blocks multiple peripheral nerves in a
specific body region
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Field block
Nerve block
Spinal block
Epidural block
Nerve Block Sites
Spinal and Epidural Anesthesia
Complications of Local or
Regional Anesthesia
Anaphylaxis
 Incorrect delivery technique
 Systemic absorption
 Overdose
 Local complications
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Treatment of Complications
Establish open airway.
 Give oxygen.
 Notify the surgeon.
 Fast-acting barbiturate is usual
treatment.
 Epinephrine for unexplained
bradycardia.
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Gerontologic Considerations
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Elderly patients at increased risk for
complications of surgery, anesthesia
due to:
– Multiple health issues
– Aging heart, lungs
– Decreased homeostatic mechanisms
– Changes in responses to drugs due to
aging changes (decreased renal function)
– Changes in body composition of fat, water
Nursing Interventions for the
Patient in the Intraoperative
Period
Reduce anxiety
 Reduce latex exposure
 Prevent intraoperative positioning
injuries
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Protect patient from injury
 Serve as patient advocate
 Monitor, manage potential
complications
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Protect the Patient from Injury
Patient identification
 Correct informed consent
 Verification of records of health history,
exam
 Results of diagnostic tests
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Allergies (include latex allergy)
 Monitor, modify physical environment
 Safety measures (grounding of
equipment, restraints, not leaving a
sedated patient)
 Verification, accessibility of blood
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