Intraoperative care

Intraoperative care 150 150 Tony Guo

Intraoperative care

 

  • Historically, took place in OR
  • Now majority are ambulatory surgeries
  • Increase minimally invasive surgery (MIS)
    • Endoscopes
    • Other advanced technology
  • Specialties with highest numbers of surgical patients
    • Ophthalmology
    • Gynecology
    • Plastic surgery
    • Otorhinolaryngology
    • Orthopedic surgery
    • General surgery (e.g., hernia repair)
  • Surgical suite
    • Controlled environment
    • Designed to minimize spread of pathogens
    • Allows smooth flow of patients, staff, and equipment
  • Physical environment
    • Unrestricted areas
      • People in street clothes interact with those in scrubs
  • Holding area
  • Locker room
  • Information areas
  • Nursing station
  • Control desk
  • Semi-restricted areas
    • Peripheral support areas and corridors with only authorized staff
    • Must wear surgical attire and cover all head and facial hair
  • Restricted areas
    • Operating rooms
    • Scrub sink areas
    • Sterile core
    • Surgical attire, head covers, and masks required
  • Holding area
    • Waiting area inside or adjacent to surgical suite
    • Final identification and assessment
    • Friends/family allowed
    • Application of sequential compression devices (SCDs)
    • Minor procedures
  • AOD area
    • Admission, observation, and discharge area
  • Early morning admissions
  • Outpatient surgery
  • Same-day admission
  • Inpatient holding
  • Operating room
    • Geographically, environmentally, and aseptically controlled
    • Restricted inflow and outflow of personnel 
    • Preferred location is next to PACU and surgical ICU
    • Filters
    • Controlled airflow
    • Positive air pressure
    • UV lighting
    • No dust-collecting surfaces
    • Materials resistant to corroding

Surgical team

  • Perioperative nurse
    • Is a registered nurse (RN)
    • Prepares room with team
    • Serves as patient advocate throughout surgical experience
      • Maintains patient safety, privacy, dignity, confidentiality
      • Communicates with the patient
      • Provides physical care
  • Scrub nurse
    • Follows designated surgical hand asepsis procedure
    • Gowned and gloved in sterile attire
    • Remains in sterile field
  • Circulating nurse
    • Not scrubbed, gowned, or gloved
    • Remains in unsterile field 
    • Documents
  • LPN or surgical technician
    • Performs scrubbed or circulating function
    • Passes instruments and implements other technical functions during procedure
    • Supervised by RN
  • Surgeon
    • Physician who performs the procedure
    • Is responsible for
      • Preoperative medical history
      • Physical assessment
      • Patient safety
      • Postoperative management
  • Surgeon’s assistant can be a physician, RN, or PA who functions in assisting role
    • Holds retractors
    • Assists with homeostasis and suturing
    • May perform portions of procedure under direct supervision
  • Registered Nurse First Assistant (RNFA)
    • Must have formal education
    • Works collaboratively with the surgeon, patient, and surgical team
      • Handles tissue
      • Uses instruments
      • Provides exposure to surgical site
      • Assists with homeostasis
      • Performs suturing
  • Anesthesia care provider (ACP)
    • Administers anesthesia
    • Anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA)
    • Maintenance of physiologic homeostasis throughout intraoperative period
    • Provide care during recovery

 

Nursing management

  • Admitting patient
    • Reassessment
    • Last-minute questions
    • Review of chart 
    • Review labs
    • Final questioning about valuables, prostheses, contacts, last intake of food/fluid
  • Basic aseptic technique
    • Center of sterile field is site of surgical incision
    • Only sterilized items in sterile field
    •  Protective equipment
      • Face shields, caps, gloves, aprons, and eyewear
  • Preparing surgical site
    • Scrub or clean around the surgical site with antimicrobial agents
      • Use a circular motion from clean to dirty area
      • Allow to fully dry
    • Hair may be removed with clippers
    • Surgical site is draped
  • Preventing hypothermia
    • Closely monitor temperature
    • Apply warming blankets
    • Warm IV fluids

 

Anesthesia

  • Anesthetic technique and agents are selected by the ACP that consider
    • Physical and mental status
    • Age
    • Allergy and pain history
    • Expertise of the ACP
    • Factors related to operative procedure
  • Classification of anesthesia
    • General anesthesia
      • Rarely use only one agent
  • Adjuncts
  • Dissociative anesthesia
  • Ketamine (Ketalar)
  • Adjuncts to general anesthesia
    • Opioids
  • Sedation and analgesia
  • Induction and maintenance intraoperatively
  • Pain management postoperatively
  • Respiratory depression
  • Assess respiratory rate and rhythm, monitor pulse oximetry, protect airway in anticipation of vomiting.
  • Use standing orders for antipruritics and antiemetics.
  • Reverse opioid-induced respiratory depression with naloxone (Narcan). If used, reversal of analgesic effects also occurs.
  • Benzodiazepines
    • Premedication for amnesia
    • Induction of anesthesia
    • Monitored anesthesia care
  • Monitor level of consciousness. Assess for respiratory depression, hypotension, and tachycardia.
  • Reverse severe benzodiazepine-induced respiratory depression with lumazenil (Romazicon).
  • Neuromuscular agents
    • Promote skeletal muscle relaxation (paralysis) 
  • If intubated, monitor return of muscle strength, level of consciousness, and ventilation.
  • Maintain patent airway. Monitor respiratory rate and rhythm until patient able to cough and return to previous levels of muscle strength. Ensure availability of nondepolarizing reversal agents (e.g., neostigmine [Prostigmin]) and emergency respiratory support equipment.
  • Monitor temperature and levels of muscle strength with temperature changes.
  • Antiemetics
    • Prevent nausea and vomiting associated with anesthesia
  • Monitor heart rhythm, cardiopulmonary status, level of central nervous system excitation or sedation, ability to move limbs, presence of nausea or vomiting
  • Local anesthesia
    • Loss of sensation without loss of consciousness
    • Types
      • Topical
      • Ophthalmic
      • Nebulized
      • Injectable
  • Regional anesthesia
    • Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked by administration of local anesthetic
    • Always injected

 

Gerontologic considerations

  • Anesthetic drugs should be carefully titrated
  • Assess for poor communication
  • Risk from tape, electrodes, and warming/cooling blankets
  • Osteoporosis and osteoarthritis
  • Perioperative hypothermia

 

Catastrophic events in the OR

  • Anaphylactic reactions
    • Manifestation may be masked by anesthesia
    • Vigilance and rapid intervention are essential
    • Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema
  • Malignant hyperthermia
    • Rare metabolic disorder
    • Hyperthermia with rigidity of skeletal muscles
    • Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents
    • Usually occurs under general anesthesia but may also occur in recovery
    • Other triggers
      • Trauma
      • Heat
      • Stress
    • Autosomal dominant trait
      • Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium
    • Tachycardia
    • Tachypnea
    • Hypercarbia
    • Ventricular dysrhythmias
    • Rise in body temperature NOT an early sign
    • Can result in cardiac arrest and death

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