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Intraoperative Care
  • Nursing care requires understanding of surgery and surgical interventions in order to monitor the pt's response
  • Nurse must keep current on technologies
  • maintain asepsis in surgical enviroment
  • continue to be strong advocate for pt
Physical Enviroment: Surgical Suite
  • Controlled enviroment
  • designed to minimize the spread of infections
  • Allows smooth flow of patients, personnel, instruments, and equipment.
Physical Enviroment: Surgical Suite
  • Unrestricted Areas: waiting and holding areas
  • Semi-restricted: OR hallways
  • Restricted: OR, clean core
Physical Enviroment: Holding Area
  • waiting area inside or adjacent to surgical area
  • final identifications and assessment
  • Minor procedures performed (IVs, Arterial Lines)
  • Friends/Family allowed
Physical Enviroment: OR
  • Geographically, enviromentally, bacteriologically controlled
  • restricted inflow and outlfow of perosnnel
  • preferred locatin is next to PACU
  • Often near the ICU
Physical Enviroment: OR
  • Filters
  • Controlled airflow
  • positive air pressure
  • materials resistant to corroding
  • electronics frequently checked for fraying to prevent fires
Perioperative team
  • perioperative nurse:
  • prepares room with team
  • pt advocate throughout surgical experience
Before surgery
  • psychosocial assessment
  • pt education
  • physical assessment for baseline data
  • check for herbs and supplements (d/t increased risk for complications)
Before surgery
  • check overall pt cleanliness
  • check NPO status
  • assess pain
  • remove piercings and jewlery
  • check sight vision
Before surgery: chart review
  • H&P
  • UA
  • CBC
  • serum lytes
  • CXR
  • ECG
Before surgery
  • Diagnostic tests (i.e. CT scan)
  • pregnancy testing
  • surgical and blood transfusion consent
  • Allergies
  • Type and crossmatch
Admitting pt
  • greet the pt
  • extend human contact and warmth
  • Id the patient
  • take glasses, hearing aid, prosthesis
  • start IV
  • palce surgical cap on pt
Room Preperation
  • surgical attire is worn by all persons entering OR suite
  • electrical and mechanical equipment checked for proper function
  • check foley, pulse-ox, leads, grounding pad
Tranferring patient
  • pt is transported into OR after preperation
  • ensure sufficient number of staff to lift, guide, and prevent falls
Scrubbing, gowning, and gloving
  • cleanse hands and arms by scrubbing with detergent and brush
  • eliminates dirt and oil
  • decreases microbes
  • standard procedure for personnel
  • sterile gown and gloves put on after scrub
Basic Aseptic technique
  • the surgical incision should be in the center of the sterile field
  • only sterile items can touch the field
  • protective equipment is worn (face shields, caps, gloves, aprons, and eyewear)
Assisting with anesthesia care
  • understand the mechanism of anesthetic administration
  • know location of emergency equipment and drugs in the OR
Position the pt to facillitate:
  • accessibility of operative site
  • administration and monitoring of anesthetic agents
  • maintenance of the airway
  • correct skeletal alignment
  • surgical scrub of pt
  • draping of the pt
General Anesthesia
  • Technique of choice for patients
  • loss of sensation with loss of conciousness
  • skeletal muscle relaxation
  • analgesia
  • eliminates somatic, autonomic, and endocrine respones (i.e. cough, vomiting, and sympathetic responses)
  • good for pts in awkwad positions, pts who cant sit still (children, parkinsons) or for pt preference
Concious Sedation
  • drug induced depression of conciousness
  • pat maintains own airway but yet achieves pain control
  • combination of anxiolytic (versed) and an opioid (fentanyl)
  • provides anagesia, relieves anxiety, and/or provides amnesia
  • can cause respiratory depression, hypoxia, and hypotension
Inducing anesthesia
  • IV agents: induce pleasant sleep, rapid onset
  • Inhalation agents: enter through alveoli, rapid excretion by ventilation
  • Complications: coughs, bronchospasms, increased secretions
  • LMA: laryngeal mask airway
  • ET tube
Adjuncts to anesthesia: Opiods
  • sedation and analgesia
  • induction and maintenance intraoperatively
  • pain management post-op
  • respiratory depression
  • fentanyl
  • Narcan reverses
Adjuncts to anesthesia: benzodiazepines
  • premedication for amnesia
  • induction of anesthesia
  • concious sedations
  • versed
  • Romazicom (reversal agent)
Adjuncts to general anesthesia: neuromuscular agents
  • Facilitate ET intubation
  • relaxation/paralysis of skeletal muscles
  • interrupt transmission of nerve impulses at neuromuscular junction
  • Succinylcholine (Anectine): depolarizing, works on nerve side, cannot be reversed
  • Nondepolarizing: work on muscle side, can be reversed (Prostigmin, Mestinon, Tensilon)
Adjuncts to general anesthesia: antiemetics
  • prevent N/V associated with anesthesia
  • Zofran
  • Compazine
  • Phenergan
  • Female non-smokers with motion sickness more likely to vomit
Classifications of anesthesia: Local
  • loss of sensation without loss of conciousness
  • Delivered topically, intracutaneously, subcutaneously
  • Local anesthesia produces ANS blockade, anesthesia, and skeletal muscle paralysis in area of affected nerve
Classifications of anesthesia: regional
Loss of sensation in body region without loss of conciousness when specific nerve or group of nerves is blocked with administration of local anesthetic
Methods of Administration
  • Topical: EMLA cream, aply 30-60 min before procedure
  • Local infiltration: inject agent into tissues through which incision will be
  • Spinal anesthesia
  • Epidural blocks (more common that spinal with less side effects)
  • deliberate lowering of body temperature to decrease metabolism
  • reduces demand for O2 and anesthesia
Malignant Hyperthermia
  • catastrophic event
  • rare metabolic disease
  • hyperthermia with rigidity of skeletal muscles
  • can result in death
  • ↑ temp
  • hypoxia
Malignant Hyperthermia cont.

  • often occurs in response to succinylcholine especially in response with inhalation agents

  • usually occurs under general anesthesia but ma also occur in recovery

  • screening is the best tool for prevention

Malignant Hyperthermia

  • inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium

  • Tachycardia

  • Tachypnea

  • Hypercarbia

  • Ventricular dysrhythmias

  • Rise in body temp NOT and early sign

  • can result in cardiac arrest and death

Nursing management after surgery

  • ACP and periop team transport pt to PACU and give report

  • PNDS (periop nursing data set) reflects standards of nursing care in any periop setting

  • Report should include blood loss and anesthesia used

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