Transcript OR Experience - Faculty Sites

OR Experience
BY: Diana Blum RN MSN
Metro Community College
Preoperative
• Begins with the scheduling of procedure
• Ends at time of transfer to surgical suite
• Places emphasis on safety and client
education
▫ 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
• http://www.youtube.com/watch?v=of-y32jBZl4
Procedures
• Categorized by:
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Reason for procedure
Urgency of the procedure
Degree of risk
Anatomic location
GUIDELINES ON P.587
Types of Surgery
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Cosmetic
Palliative
Reconstructive
Elective
Urgent
Emergent
Curative
Exploratory
Diagnostic
Surgical Areas
• 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
ASSESSMENT
• Preoperative health evaluation
▫ 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)
Risk Factors
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Elderly
Obesity
Diabetes
Heart conditions
Renal failure
Assessment
• History
▫ 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
• Physical
▫ important to obtain baseline assessment, complete vitals, report
abnormal findings to doctor
• Psychosocial
▫ 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
▫ Provides a baseline for the client
▫ Helps predict potential complications
• Radiographic
▫ Provides baseline and looks at size & shape of heart and lungs
• Diagnostics
▫ EKG- used as baseline. Looks for old MI, or other complications that
could postpone surgery
Question
• Which diuretic can cause problems in surgery?
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A. lasix
B. hydrochlorothiazide
C. valium
D. benadryl
• Lasix and hydrochlorothiazide may cause
excessive respiratory depression resulting from
an associated electrolyte imbalance
Nursing Diagnosis
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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
Education
• 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.
• 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
Legal Responsibilities
• DNR
• DNI
• Must be clearly documented
Surgical Prep
• Bowel prep
• Skin prep-shower, hair removal (clippers)
▫ (see pg 610)
• Preoperative meds
▫ Antibiotic
Tubes, drains, vascular access
• Pt must be educated prior to surgery
▫ Reduces fear
• Tubes
▫ Foley- monitors renal function
▫ NG-used for abd surgery to decompress the stomach
• Drains
▫ Removes fluid for surgical site.
▫ CT, JP, Hemovac, Orthopat
• Vascular access
▫ For anesthesia
▫ For drugs and fluids
Respiratory education
• Incentive spirometry
▫ 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
• Deep breathing
▫ Sit upright, feet firm on ground, gentle breath through mouth,
exhale gently
• Expansion breathing
▫ 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
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
Aka “sexy socks”
Anxiety reduction
• Distraction
• Promote rest
• Guided imagery
Gerontological Considerations
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Go over instructions slower
Have family present
Co-existing disease increases risk
Positioning
Intra op
Nursing diagnosis
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Risk for infection
Impaired skin integrity
Altered body temperature
Anxiety
Injury related to positioning and other hazards
Members
• Surgeon
▫ heads surgical team
▫ Makes decisions related to surgical procedure
▫ May need assistant
• Surgical assistant (other doctor, surgical tech,
resident, intern)
▫ May hold retractors, suction wound, cut tissue, suture,
and dress wounds depending on scope of practice and
under supervision of physician
• Anesthesia
▫ Anesthesiologist or Certified Registered Nurse
Anesthestist
▫ Maintains airway
▫ Monitoring circulation/respiratory status
▫ Replace blood/fluid loss
• 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
• Operating Room
▫ Restricted area
▫ Trend towards less invasive procedures (less
scarring, quicker recovery, decreased length of
hospitalization
Basic Guidelines for Surgical Asepsis
• 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.
• 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.
• http://www.youtube.com/watch?v=EvpcGmExsd4&feat
ure=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
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”
▫ Name, procedure, site, document
▫ See pg. 612
Anesthesia
• http://www.youtube.com/watch?v=WOrjcLJ2IE
0&NR=1
Anesthesia
• 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
General
• Definition: reversible loss of consciousness
induced by inhibiting neuronal impulses in
several areas of the central nervous system
▫ 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
• 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
• Inhalation: most controllable
▫ Fast acting
▫ Passes through vaporizer
▫ Depresses CNS
 Ex: Nitrous Oxide
• IV: rapid and pleasant
▫ Induce and maintain anesthesia
▫ Anesthetics
Opiods
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Etomidate
Valium
Versed
Diprivan
Fentanyl
Morphine
▫ Reversal agent for opoids=Narcan (0.2mg)
▫ Reversal agent for Benzos =
Romazicon(0.2mg)
• Muscle relaxants
▫ Affect skeletal muscle
▫ Administered before intubation
▫ Assess with nerve stimulator
▫ Succinylcholine, Tracrium, Vecronium
▫ Reversal agent= Neostigmine (0.5-2mg
• Balanced: minimal disturbance to function, used
with elderly and high risk
• 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
• Spinal
▫ Local anesthetic injected into subarachoid space,
directly into CSF
▫ “Blocks” at level of spinal cord (sensory and
motor)
• Epidural
▫ Local anesthetic into epidural space
• Peripheral nerve block
▫ Anesthesia of a certain area
▫ No systemic effect
Intraoperative Complications
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Nausea and vomiting
Anaphylaxis
Hypoxia and respiratory complications
Hypothermia
Dysrhymias
Malignant hyperthermia
Disseminated intravascular coagulation
(DIC)
Malignant Hyperthermia
▫ Life threatening
▫ Predisposition is genetic
• 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
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*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
Intubation complication
• Broken or chipped teeth
• Swollen lip
• Vocal cord trauma
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
b. 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.
Local
• Numbing agent is used
• Mentally alert
• Complications: potential cardiac depression,
toxic reaction, edema, blurred vision,
inflammation, etc. see
Types of local
• Topical
• Infiltration: directly into wound or lesion
• Blocks:
▫ Field: injections around work site (lidocaine, novocaine)
▫ Nerve: injection into or around nerve in involved areaused for chronic pain relief
▫ Spinal: injection of agent into CSF in the subarachnoid
space-absorbed rapidly
▫ Epidural: placed in epidural space-may affect breathing
Moderate (Conscious) Sedation
• Moderate (Conscious) sedation
▫ Minimally depressed LOC
▫ Pt able to maintain airway
▫ Pt responds to physical and verbal stimuli
Moderate (Conscious) Sedation
• As a nurse, what do you need to have available at
the bedside?
• What medications might be given?
• What monitoring/assessments?
• What types of procedures?
Potential Adverse Effects of Surgery and
Anesthesia
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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
• http://www.youtube.com/watch?v=7MZ
qB4EWlZg
Gerontologic Considerations
• Elderly patients are at increased risk for
complications because of:
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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
Important to remember
• 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
• 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
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Accommodates access
Surgical view
Maintain skin integrity (pressure ulcers)
Injury to nerves may happen
Prevent injury
Complications:
▫ Compromised respiratory status, pressure ulcers,
injury to nerves
Surgical positions
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Supine
Trendelenburg
Prone
Lateral
Jackknife
lithotomy
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Bariatrics
• 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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• Antiobesity drugs:
• 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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Bariatric Surgery
• Roux en Y: most commonly performed
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- least likely to result in nutritional
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deficiencies
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- small bowel is divided & arranged
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into a “y” and attached to the small
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stomach pouch
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- pt feels fullness rapidly after eating
Post op
• Starts at the completion of surgery and transfer
to PACU or ICU
▫ Stabilize VS, maintain airway
▫ Prepare pt for discharge
• 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
• 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
• 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
▫ Monitor wound, drainage, drains, dressings,
• Early infection can be
indicated on increase in band
cells of the WBC differential
(left shift)
• Get culture
• Notify MD
• 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
Nursing diagnosis
Impaired Gas Exchange
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Open airway
Breathing pattern improved over baseline
Adequate O2 saturation
Provide supplemental oxygen
Artificial airway if patient is minimally
responsive
• Cough deep breath, IS
Risk for Imbalanced Fluid Volume
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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
Risk for Decreased Cardiac Output
• 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
• 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
• 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
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
• Partial or complete separation of wound layers
• Wound is open
• Prevention?
Evisceration
• Complete separation of wound layers
• Protrusion of internal organs
• Usually occurs 5-10 days post-op
• Prevention?
Dehiscence
Evisceration
Complications
on chart 27-4
Surgical Site Infections
(SSI)
• Aseptic technique
• Most infections are caused by exogenous
organisms
• Surgical wound classification (pg. 636)
• Risks:
▫ Obesity, smokers, malnourishment
Atelectasis and Pneumonia
• 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
Gastrointestinal
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N/V
Flatus
Bowel sounds
Ileus-hypoactive bowel, delay in peristalsis
Urinary Retention
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Foley cath
Must void within 6-8hrs
Anesthesia causes relaxation, retention
May have swelling from certain procedures
DVT
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LWM- Heparin or lovonox
SCD
TEDS
Ambulation
Leg exercises