1
Q
Perioperative Nursing
A
- Preoperative begins when patient is scheduled for surgery ; ends at time of transfer to bed of surgical suite
- Nurse functions as educator, advocate, promoter of health and safety
- Patient is prepared for surgery
— Identification
— Assessment
— Consent
— Teaching
2
Q
Reasons for Surgery
A
Diagnostic
- Determine origin and cause of disorder
Curative
- Resolves health problems by repairing/removing cause
Restorative
- Improves patient’s functional ability
Palliative
- Relieve symptoms of disease process, but not a cure
Cosmetic
- Alters/enhances personal appearance
3
Q
Preoperative Role of Nurse
A
Assessment:
- History (previous surgery & anesthesia)
- Systems
- Labs, Dx. Tests
Psychosocial
- Informed consent:
- Surgeon obtains signed consent before sedation and/or surgery
- Nurse clarifies facts and dispels myths about surgery
- Nurse not responsible for providing detailed info about procedure!
- Patient may sign with an X
Teaching
- Environment
- Equipment
4
Q
Consent
A
- Must Be Voluntary
- NO PAIN MEDS PRIOR TO SIGNING CONSENT!
- In writing
- Contain the following:
— Explanation of procedure and its risks
— Description of benefits and alternatives
— An offer to answer questions about procedure
— Instructions that the patient may withdraw consent
— A statement informing the patient if the protocol differs from customary procedure - Patients must be able to understand, whether it be an issue of language, hearing impaired or cognitively impaired.
5
Q
Pre Op Nurse Responsibility
Preparation for Surgery
A
- History of Medications
- Allergies
- Consent Is it signed
- Advanced Directive
- Preoperative Medication
- Pre op Blood
- NPO 6-8 hours pre surgery
- Surgical checklist
- Preoperative Unit
— Review of chart
— Education of patient
— Right site
— Meeting team (surgeon, anesthesiologist, circulating nurse)
6
Q
Collaborative Management
A
- 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
7
Q
Older Adults: Considerations for Preop Care
A
- Chronic illness
- Malnutrition
- Impaired self-care ability
- Inadequate support systems
- Stress from surgery/anesthesia
- Cardiopulmonary complications after surgery
- Mental status changes
- Risk for falls
8
Q
- Gerontologic Considerations
A
- *Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors:
— *Age-related cardiovascular and pulmonary changes
— *Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass
— *Decreases the rate at which the liver can inactivate many anesthetic agents
— *Decreased kidney function slows the elimination of waste products and anesthetic agents
— *Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms
9
Q
Intraoperative
A
- Intraoperative begins when the patient enters the surgical suite and ends at the time of transfer to the post anesthesia recovery area, same-day surgery unit, or the intensive care unit.
- The main concerns of perioperative nurses are safety and patient advocacy by preventing, reducing, controlling, and managing many hazards.
- Begins with the patient entering the surgical suite, ends with the transfer of the patient to the post anesthesia care unit
- Nurse functions as circulating and scrub nurse; advocate, promoter of health and safety
- Patient undergoes anesthesia, surgical procedure What risks does the patient have in the OR?
10
Q
Members of the Surgical Team
A
- Surgeon
- Anesthesia providers (MD, CRNA)
- Circulating nurse
- Scrub nurse
- Don’t Forget the patient!
11
Q
Environment of the Operating Room
A
- Preparation of surgical suite, team safety Protection of patient by team, team safety
- Layout: Unrestricted zone, semirestricted zone & restricted zone
- Health and hygiene of surgical team
- Surgical attire and scrub
- Remember:
— People are source of bacteria in surgical setting!
— Special health care standards, dress are needed
— Watch for nosocomial infections, identify source of pathogens
12
Q
Environment of the Operating Room
A
- Preparation of surgical suite
- team safety
- Protection of patient by team
- Health and hygiene of surgical team
- Surgical attire and scrub
- Layout –
— Unrestricted zone- allows street clothes
— Semi restricted zone- Scrub clothes and caps
— restricted zone- scrubs, shoe covers, caps, masks
13
Q
Surgical Scrubbing
A
- Broad-spectrum, surgical antimicrobial solution
- Vigorous rubbing that creates friction used from fingertips to elbow
- Scrub continues for 3 to 5 min
14
Q
Minimally Invasive and Robotic Surgery (MIS)
A
- Now common practice
- Preferred technique for many surgery types, including:
— Cholecystectomy
— Joint surgery
— Cardiac surgery
— Splenectomy
— Spinal surgery
15
Q
Surgical Risk Factors
A
- Hemorrhage: 500mL or more
- Infection
- Ventilation
— Exacerbation of copd
— Aspiration
— Atelectasis - Perfusion
— DVT, PE, BP problems - Injury related to positioning during surgery
16
Q
Health Hazards Associated With the Surgical Environment
A
- Faulty Equipment or improper use of equipment
- Exposure to toxic substances/infectious waste
- Burns from electrical equipment
- Retained object in surgical site.
- AORN: Association of periOperative Registered Nurses
- Recommended practices
17
Q
- Older Adults: Considerations
Intraoperative Nursing Interventions
A
- *Allow patients to retain eyeglasses, dentures, and hearing aids until anesthesia has begun.
- Use a small pillow under the patient’s head if his or her head and neck are normally bent slightly forward.
- Lift patients into position to prevent shearing forces on fragile skin.
- Position arthritic and artificial joints carefully to prevent postoperative pain and discomfort from strain on those joints.
- Pad bony prominences to prevent pressure sores.
18
Q
Anesthesia not on test; know what to do when pts come back from surgery
A
19
Q
Anesthesia
A
- Induced state of partial or total loss of sensation, occurring with or without loss of consciousness
- Purpose to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, achieve controlled level of unconsciousness (in some cases)
— General
— Inhalation, IV
— Regional - epidural, spinal, and local conduction blocks
— Moderate or Conscious Sedation -monitored
— Local
20
Q
General Anesthesia
A
- State of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss.
- Involves single or combination of agents
- Depresses CNS, resulting in analgesia, amnesia, and unconsciousness with loss of muscle tone and reflexes
- Administered via:
— Inhalation
— IV injection
— Balanced anesthesia
21
Q
Four stages of General Anesthesia
A
- Stage 1: Beginning Anesthesia
— Dizziness and detachment - Stage 2: Excitement
— eg. struggling shouting, singing - Stage 3: Surgical Anesthesia
— Patient unconscious - Stage 4: Medullary depression
— Too much anesthesia. Without intervention death will follow.
22
Q
Balanced/Combination Anesthesia
A
- Combination of IV drugs and inhalation agents used to obtain smooth transition from one stage to another.
- Begin with inhalation then move to IV
- Provide close observation of responses of
— Pupils
— B/P
— HR
— Resp Rate - Table 18-1 Inhalation Anesthetic Agents given with nitrous oxide and Oxygen
23
Q
Complications from General Anesthesia
A
- Anesthesia Awareness
- Nausea and Vomiting
- Anaphylaxis
- Hypoxia/Respiratory Complications
- Hypothermia
- Overdose
- *Malignant hyperthermia
24
Q
- Malignant Hyperthermia
A
- An Acute, life-threatening complication
— May be caused by genetics
— Rare - It occurs in 1 in 50,000 to 100,000 adults.
— Mortality as high as 70%
— Begins with skeletal muscle exposed to specific agent (body builders)
— Causes increased metabolism and calcium levels in muscle cells
— Increases serum Ca and K:
— Increased CO2 first sign
— Hyperthermia (Late sign/ last)
— Tachycardia
— Myoglobinuria - Leads to acidosis, high temperatures, dysrhythmias
25
* Clinical Manifestations of Malignant Hyperthermia
- Tachycardia (heart rate greater than 150 bpm)
- Hypotension
- Decreased Cardiac Output
- Hypercapnia- increase in CO2 (early sign)
- Rigidity of muscles
- Elevated temperature (late sign)
26
Treatment for Malignant Hyperthermia
- Prompt recognition of symptoms
- O2/Hyperventilation
- Hydration/Normal saline
- * Med: Dantrolene
- Body Cooling
- Meds for acidosis, Hyperkalemia, and dysthymias.
— give sodium bicarbonate
— maybe IV insulin
— cardiac meds
27
Capnometry and Capnography
- Methods that measure the amount of carbon dioxide present in exhaled air, which is an indirect measurement of arterial carbon dioxide levels.
- Non Invasive
- Capnometry is exhaled air tested with a sensor, changes color or number with analysis
- Capnography is the wave form along with a number on a monitor that measures CO2 levels
- Used on both intubated and those breathing on their own
- Normal values of partial pressure of end tidal carbon dioxide (PETCO2) 20-40 mg Hg.
28
Regional Anesthesia
- Anesthetic agent injected around nerve to anesthetize the area.
- Patient awake
- Epidural – epidural space
- Spinal – subarachnoid space
29
Local Anesthesia
- Briefly disrupts sensory nerve impulse transmission from specific body area/region
- Delivered topically and by local infiltration
- Patient remains conscious, able to follow instructions
30
Complications of Local or Regional Anesthesia
- Anaphylaxis
- Incorrect delivery technique
- Systemic absorption
- Overdose
- Local complications
31
Moderate Sedation
- Previously called Conscious Sedation
- IV delivery of sedative, hypnotic, opioid drugs to reduce level of consciousness
- Patient maintains patent airway, can respond to verbal commands
- Amnesia action is short
- Monitored Anesthesia Care – MAC
- given by an anesthesiologist or CRNA who must be prepared and qualified to convert to general anesthesia if necessary
32
Common Surgical Positions
33
Potential for Injury
Interventions:
- Proper body position
- Prevent pressure ulcer formation
- Prevent obstruction of circulation, respiration, nerve conduction
34
Postoperative
- Postoperative period starts with completion of surgery and transfer of pt to specialized area for monitoring eg. post anesthesia care unit (PACU)
- Patient recovers from anesthesia, monitored for complications of surgery
- Can continue after discharge from the hospital until all activity restrictions have been lifted.
- Divided into three phases based on the level of care needed
— Phase 1 immediately after surgery
— Phase 2 preparing patient for extended care
— Phase 3 Hospital or home for pts requiring continuing care
35
Post operative Nursing
- Patient goes to post anesthesia unit with nurse and anesthesiologist
- Report given to receiving nurse
- Monitoring of:
— anesthesia wearing off
— Pain control
— Surgical site
— Drains
— I&O
- Vital signs and assessment
- Every 15 minutes first hour, every 30 mins second hour, then every hour PRN
- Equipment
— EKG monitor- SpO2, BP, Temperature
- Length of stay 1-3 hours
- Remember the family: Did MD speak with family, Communication is important to family members
36
Comfort Measures
- Pt may feel the following up to 24 hours post op
— Sore throat
— Aching muscles
— General malaise
— Shivering – not uncommon
- Provide if needed:
— Warm cotton blankets applied as necessary
— Warm air blanket may be utilized
— Medication is used for extreme shivering
37
Potential for Infection
Interventions:
— Plastic adhesive drape
— Skin closures, sutures and staples, nonabsorbable sutures, Insertion of drains
— Application of dressing
— Patient transfer from OR table to stretcher
38
Common Skin Closures
39
Question 1
The nurse is monitoring a patient who is receiving moderate sedation. An expected outcome for conscious sedation is:
- A. Blocked multiple peripheral nerves in a specific region
- B. Decreased motor function in the targeted limb
- C. Decreased level of consciousness, yet able to respond to verbal commands
- D. CNS depression, resulting in analgesia and amnesia, with loss of muscle tone and reflexes
C
40
Question 2
During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention?
- A. Communicate the discrepancy to the surgical team immediately.
- B. Complete appropriate documentation concerning the error in sponge count.
- C. Examine the environmental distractions, refocus, and count the sponges again.
- D. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively.
C?
41
Question 3
The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present?
- A. Diabetes mellitus
- B. Age greater than 65
- C. Impaired liver function
- D. Insertion of a surgical drain
42
Question 4
The nurse is monitoring a patient who has received conscious sedation (moderate sedation) What are the expected outcomes for this patient?
- A. Block specific peripheral nerves in a specific region
- B. Decrease LOC yet able to respond to verbal commands
- C. Decrease motor function in the target area
- D. CNS depressant, amnesic effect and loss of muscle tone
B?
43
Question 5
While at the scrub sink, the scrub person informs the circulating nurse that she now wears artificial nails because her own nails break frequently posing a risk for a glove puncture. What is the nurse’s best response?
- A. Ask the scrub person to wear double-gloves to prevent puncture or contamination.
- B. Confirm with the scrub person that artificial nails are acceptable and do not affect hand hygiene.
- C. Support the scrub person’s rationale that broken nails are a serious source of cross-contamination.
- D. Remind the scrub person that artificial nails alter skin flora, impede hand hygiene, and are not permitted.
D?
44
Question 6
Which change in the anesthetized client alerts the nurse to the possibility of malignant hyperthermia?
- a) Widening pulse pressure
- b) Increasing output of dilute urine
- c) Increasing end-tidal carbon dioxide level
- d) Ascending flaccid paralysis of skeletal muscles
C
