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
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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: • 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
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 • 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? • A. lasix • B. hydrochlorothiazide • C. valium • D. benadryl
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
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
Anxiety reduction • Distraction • Promote rest • Guided imagery
Gerontological Considerations • Go over instructions slower • Have family present • Co-existing disease increases risk • Positioning
Nursing diagnosis • 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 • 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&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
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=WOrjcLJ2IE0&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 • AnestheticsOpiods • EtomidateFentanyl • Valium Morphine • Versed • Diprivan • 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 • 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
Manifestations • Hypoxia • Hyperthermia****THIS IS A LATE SIGN**** • Dysrhythmias • Hypotension • Early signs: • 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
Intubation complication • Broken or chipped teeth • Swollen lip • Vocal cord trauma