The Intraoperative Patient

1. The Intraoperative Patient By Lisa M. Dunn RN, MSN/ED, CCRN

2. 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

3. 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

8. Surgical Scrub, Gowning, and Gloving

9. 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.

11. 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.

12. Stages of General Anesthesia Stage 1: analgesia Stage 2: excitement Stage 3: operative Stage 4: danger

13. 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

14. 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.

15. Balance Anesthesia Continued… Example: -thiopental for induction -nitrous oxide for amnesia -morphine for analgesia -pancuronium for muscle relaxation

16. Complications from General Anesthesia • Malignant hyperthermia: possible treatment with dantrolene • Overdose • Unrecognized hypoventilation • Complications of specific anesthetic agents • Complications of intubation

17. Question • In treating the client with malignant hyperthermia, the most important intervention is: • Initiation of cooling measures • Administration of skeletal muscle relaxant • Reversal of anesthesia • Increasing rate of intravenous fluids

18. 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.

19. Local Anesthesia • Topical anesthesia • Local infiltration • Regional anesthesia • -field block • -nerve block • -spinal anesthesia • -epidural anesthesia

22. Question • In reviewing preoperative teaching for a client scheduled to have regional anesthesia, which statement by the client indicates that additional teaching is needed? • “My legs may be numb for a while.” • “I hope I don’t get too nervous being awake.” • “It will be difficult to move my legs immediately after surgery.” • “I am relieved that I will be asleep during this procedure.”

23. Complications of Local or Regional Anesthesia • Anaphylaxis • Incorrect delivery technique • Systemic absorption • Overdosage

24. 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

25. 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.

26. 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.

27. “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).

28. 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: • An increase in pulse rate • A drop in blood pressure • Nerve and muscle damage • Muscle fatigue in the extremities

29. 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? • Ensure that the client has voided • Administer all the daily medications • Practice postoperative breathing exercises • Verify that the client has not eaten for the last 24 hours

30. 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.

31. 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.

32. Conscious Sedation Continued… Nursing Assessment Includes: -Airway -Oxygen saturation -Level of consciousness -Electrocardiographic status -vital signs monitor every 15 to 30 minutes

33. 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

34. 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? • Inhale as rapidly as possible. • Keep a loose seal between the lips and the mouthpiece. • After maximum inspiration, hold your breath for 15 seconds and exhale. • The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

35. Risk for Perioperative Positioning Injury • Interventions include: • Proper body position • Risk for pressure ulcer formation • Prevention of obstruction of circulation, respiration, and nerve conduction

37. 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

38. Special Drains • Remove pus • Remove blood • Remove other body fluids from wound • Does not result in faster wound healing or prevent infection.

39. Penrose Drain

40. Jackson Pratt or JP

41. Hemovac

42. 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

43. 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.

44. Montgomery Straps

45. 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

46. 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.

47. Question • Which of the nursing interventions would the nurse implement for the older client to minimize skin breakdown related to surgical positioning? • Padding bony prominences • Taping joints in anatomic position • Monitoring for excessive blood loss • Applying elastic stockings to lower extremities

49. Potential for Hypoventilation • Continuous monitoring of: • -breathing • -circulation • -cardiac rhythms • -blood pressure and heart rate • Continuous presence of an anesthesia provider