Nursing Care of the Nursing Care of the Intraoperative PatientIntraoperative Patient

Sharon Haas, RN, MSN, CDNCardinal Stritch University

FA 2013

IntraoperativeIntraoperative

The nurses primary responsibility The nurses primary responsibility is to insure patient safetyis to insure patient safety

Intraoperative CareIntraoperative Care

Historically, took place in ORHistorically, took place in OR

Current trend to Current trend to ↓ ↓ in-hospital in-hospital surgery and surgery and ↑ ↑ ambulatory ambulatory proceduresprocedures

Healthier patientsHealthier patients

Shorter proceduresShorter proceduresCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Intraoperative CareIntraoperative Care

Specialties with highest numbers Specialties with highest numbers of surgical patientsof surgical patients OphthalmologyOphthalmology GynecologyGynecology Plastic surgeryPlastic surgery OtorhinolaryngologyOtorhinolaryngology Orthopedic surgeryOrthopedic surgery General surgery (e.g., hernia repair)General surgery (e.g., hernia repair)

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Intraoperative CareIntraoperative Care

Nursing care requires an understanding Nursing care requires an understanding of of

AnesthesiaAnesthesia PharmacologyPharmacology SurgerySurgery Surgical interventionsSurgical interventions

Allows you to monitor patient’s responseAllows you to monitor patient’s responseCopyright © 2011, 2007 by Mosby, Inc., an affiliate

of Elsevier Inc.

Intraoperative CareIntraoperative Care

You must keep current on You must keep current on technologies.technologies.

Maintain asepsis in the surgical Maintain asepsis in the surgical environment.environment.

Continue to be a strong advocate Continue to be a strong advocate for the patient.for the patient.

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Physical EnvironmentPhysical Environment

Holding areaHolding area Waiting area inside or adjacent to Waiting area inside or adjacent to

surgical areasurgical area Final identification and assessmentFinal identification and assessment Friends/family allowedFriends/family allowed Surgical Care Improvement Project Surgical Care Improvement Project

(SCIP) measures to implement here(SCIP) measures to implement here Patient warmingPatient warming Prophylactic antibiotic administrationProphylactic antibiotic administration Application of sequential compression Application of sequential compression

devicesdevicesCopyright © 2011, 2007 by Mosby, Inc., an affiliate

of Elsevier Inc.

Surgical SuiteSurgical Suite

Unrestricted Areas Semi-Restricted Areas

Restricted Areas

Personnel in street clothes interact with those in scrubs.Holding areaLocker roomInformation areas

Nursing stationControl desk

Peripheral support areas and corridors with only authorized peopleMust wear surgical attire and cover all head and facial hair

Operating roomsScrub sink areasClean coreSurgical attire, head covers, and masks required

Surgical TeamSurgical Team

Perioperative NursePerioperative Nurse Prepares the room with the teamPrepares the room with the team Patient AdvocatePatient Advocate

Circulating NurseCirculating Nurse Not scrubbed, gowned or glovedNot scrubbed, gowned or gloved Remains in unsterile fieldRemains in unsterile field DocumentsDocuments

Scrub NurseScrub Nurse Scrubbed inScrubbed in Remains in sterile fieldRemains in sterile field

Nursing ManagementNursing Management

Safety considerationsSafety considerations Smoke particlesSmoke particles Grounding padGrounding pad Universal protocolUniversal protocol

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Circulating NurseCirculating Nurse

Responsible for all of the activities within Responsible for all of the activities within their assigned ORtheir assigned OR

Set-up for the procedureSet-up for the procedure Checks equipmentChecks equipment Primary RN who communicates with the ptPrimary RN who communicates with the pt Positions patient on the OR tablePositions patient on the OR table Preps surgical sitePreps surgical site

Nursing ManagementNursing Management

Positioning of patientPositioning of patient Accessibility of operative siteAccessibility of operative site Administration and monitoring of Administration and monitoring of

anesthetic agentsanesthetic agents Maintenance of airwayMaintenance of airway Correct skeletal alignmentCorrect skeletal alignment Prevent pressure on nerves, skin, Prevent pressure on nerves, skin,

bony prominences, or eyes.bony prominences, or eyes. Provide for adequate thoracic Provide for adequate thoracic

excursion.excursion.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing ManagementNursing Management

Positioning of patientPositioning of patient Prevent occlusion of arteries and Prevent occlusion of arteries and

veins.veins. Provide modesty in exposure.Provide modesty in exposure. Recognize and respect needs such as Recognize and respect needs such as

pain or deformities.pain or deformities. Prevent injuryPrevent injury

Patient will not feel pain impulses because Patient will not feel pain impulses because of anesthesia.of anesthesia.

Secure extremities.Secure extremities. Provide adequate padding and support.Provide adequate padding and support.Copyright © 2011, 2007 by Mosby, Inc., an affiliate

of Elsevier Inc.

OR PositioningOR Positioning

ScrubScrub NurseNurse

Sets up the sterile field and sterile instruments to Sets up the sterile field and sterile instruments to be used in the procedurebe used in the procedure

Provides surgeon with instrumentsProvides surgeon with instruments

MUST understand anatomy and physiology of the MUST understand anatomy and physiology of the bodybody

Maintain accurate sponge and needle count Maintain accurate sponge and needle count throughout procedurethroughout procedure

Accounts for all instrumentsAccounts for all instruments

Accounts for all irrigation fluid usedAccounts for all irrigation fluid used

AnesthesiaAnesthesia

Anesthesia is an artificially induced state of Anesthesia is an artificially induced state of partial or total loss of sensation, occurring partial or total loss of sensation, occurring with or without loss of consciousnesswith or without loss of consciousness

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General AnesthesiaGeneral Anesthesia Reversible loss of consciousnessReversible loss of consciousness Central nervous system is depressed, resulting in Central nervous system is depressed, resulting in

analgesia, amnesia, and unconsciousness, with loss of analgesia, amnesia, and unconsciousness, with loss of muscle tone and reflexes.muscle tone and reflexes.

Technique of choice for surgeries with significant Technique of choice for surgeries with significant duration or that require relaxation/uncomfortable duration or that require relaxation/uncomfortable position/control of respirationposition/control of respiration

Loss of sensation with loss of consciousnessLoss of sensation with loss of consciousness May be induced by IV or inhalationMay be induced by IV or inhalation

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Stages of General Stages of General AnesthesiaAnesthesia

Stage 1: analgesiaStage 1: analgesia Stage 2: excitementStage 2: excitement Stage 3: operativeStage 3: operative Stage 4: dangerStage 4: danger

Types of AnesthesiaTypes of Anesthesia

InhalationInhalation: intake and excretion of anesthetic gas : intake and excretion of anesthetic gas or vapor to the lungs through a maskor vapor to the lungs through a mask

Intravenous injectionIntravenous injection: barbiturates, ketamine, and : barbiturates, ketamine, and propofol through the bloodpropofol through the blood

Adjuncts to general anesthetic agentsAdjuncts to general anesthetic agents: hypnotics, : hypnotics, opioid analgesics, neuromuscular blocking agentsopioid analgesics, neuromuscular blocking agents

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Balanced AnesthesiaBalanced Anesthesia

Combination of intravenous drugs and inhalation Combination of intravenous drugs and inhalation agents used to obtain specific effectsagents used to obtain specific effects

Combination used to provide hypnosis, amnesia, Combination used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic reflexes with minimal disturbance of physiologic functionfunction

Cascade to Malignant Cascade to Malignant HyperthermiaHyperthermia

MH susceptible person – mutation resulting in abnormal proteins in muscle cells

Exposure to anesthetic agent Abnormal release of Ca release of Ca++++ inside muscle cell inside muscle cell Sustained muscle contraction & the abnormal increase in

energy utilization and heat production Muscle cells eventually run out of energy and die Large amounts of K+ are released into the bloodstream,

heart rhythm abnormalities.  Muscle pigment myoglobin is also released and may be

toxic to the kidney Left untreated, these changes can cause cardiac

arrest, kidney failure, blood coagulation problems, internal hemorrhage, brain injury, liver failure, and may be fatal.

Malignant Hyperthermia

The general signs of the MH crisis include

tachycardia, increased body metabolism, muscle rigidity and/or fever that may exceed 110°F (43°C).

Severe complications include:  cardiac arrest, brain damage, internal bleeding or failure of other body systems.  Thus, death, primarily due to a secondary cardiovascular collapse, can result.

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Complications from General Complications from General AnesthesiaAnesthesia

Malignant hyperthermia: TX: Malignant hyperthermia: TX: DantroleneDantrolene

OverdoseOverdose Unrecognized hypoventilationUnrecognized hypoventilation Complications of specific anesthetic Complications of specific anesthetic

agentsagents Complications of intubationComplications of intubation

WHAT DRUGS TRIGGER MH?

Volatile gaseous inhalation anesthetics: Sevoflurane Desflurane Isoflurane Halothane Enflurane methoxyflurane

Depolarizing muscle relaxant: Succinylcholine (Anectine)

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Local or Regional AnesthesiaLocal or Regional Anesthesia

Sensory nerve impulse transmission from a Sensory nerve impulse transmission from a specific body area or region is briefly disrupted.specific body area or region is briefly disrupted.

Motor function may be affected.Motor function may be affected. Client remains conscious and able to follow Client remains conscious and able to follow

instructions.instructions. Gag and cough reflexes remain intact.Gag and cough reflexes remain intact. Sedatives, opioid analgesics, or hypnotics are Sedatives, opioid analgesics, or hypnotics are

often used as supplements to reduce anxiety.often used as supplements to reduce anxiety.

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Local AnesthesiaLocal Anesthesia

Topical anesthesiaTopical anesthesia Local infiltrationLocal infiltration Regional anesthesiaRegional anesthesia

Field blockField block Nerve block (brachial plexus, Nerve block (brachial plexus,

retrobulbar)retrobulbar) Spinal anesthesiaSpinal anesthesia Epidural anesthesiaEpidural anesthesia

Advantages/DisadvantagesAdvantages/Disadvantages of of

Local or Regional Anesthesia Local or Regional Anesthesia

Little systemic absorptionLittle systemic absorption Rapid recoveryRapid recovery Little residual “hangover”Little residual “hangover”

Possible discomfort, hypotension, Possible discomfort, hypotension, and seizuresand seizures

Technical difficultiesTechnical difficulties

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Complications of Local or Regional Complications of Local or Regional Anesthesia Anesthesia

AnaphylaxisAnaphylaxis Incorrect delivery techniqueIncorrect delivery technique Systemic absorptionSystemic absorption Overdose Overdose Assess for central nervous system stimulationAssess for central nervous system stimulation Central nervous system and cardiac depressionCentral nervous system and cardiac depression RestlessnessRestlessness ExcitementExcitement

(Continued)(Continued)

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Complications of Local or Regional Complications of Local or Regional AnesthesiaAnesthesia (Continued)(Continued)

Incoherent speechIncoherent speech HeadacheHeadache Blurred visionBlurred vision Metallic tasteMetallic taste Nausea and vomitingNausea and vomiting Tremors or seizuresTremors or seizures TachycardiaTachycardia Tachypnea Tachypnea HypertensionHypertension

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Treatment of ComplicationsTreatment of Complications

Establish an open airway.Establish an open airway. Give oxygen.Give oxygen. Notify the surgeon.Notify the surgeon. Fast-acting barbiturate is usual treatment.Fast-acting barbiturate is usual treatment. If toxic reaction is untreated, If toxic reaction is untreated,

unconsciousness, hypotension, apnea, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.cardiac arrest, and death may result.

Monitored Anesthesia Care (MAC)Monitored Anesthesia Care (MAC)Conscious SedationConscious Sedation

IV delivery of sedative, hypnotic, and opioid drugs reduces the IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands.patent airway and to respond to verbal commands.

Diazepam, midazolam, meperidine, fentanyl, alfentanil, and Diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulfate are the most commonly used drugs.morphine sulfate are the most commonly used drugs.

Nursing assessment of airway, level of consciousness, oxygen Nursing assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored saturation, electrocardiographic status, and vital signs are monitored every 15 to 30 minutes.every 15 to 30 minutes.

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Impaired Skin Integrity and Impaired Skin Integrity and Impaired Tissue IntegrityImpaired Tissue Integrity

Interventions include:Interventions include: Plastic adhesive drapePlastic adhesive drape Skin closures, sutures and staples, Skin closures, sutures and staples,

non-absorbable suturesnon-absorbable sutures Insertion of drainsInsertion of drains Application of dressingApplication of dressing Transfer of client from the operating Transfer of client from the operating

room table to a stretcherroom table to a stretcher

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Potential for HypoventilationPotential for Hypoventilation

Continuous monitoring of:Continuous monitoring of: BreathingBreathing CirculationCirculation Cardiac rhythmsCardiac rhythms Blood pressure and heart rateBlood pressure and heart rate

Continuous presence of an anesthesia Continuous presence of an anesthesia providerprovider

Nursing ManagementNursing Management

After surgeryAfter surgery

ACP and perioperative team ACP and perioperative team member take patient to PACU and member take patient to PACU and give report.give report.

Perioperative nursing data set Perioperative nursing data set (PNDS) reflects standards of (PNDS) reflects standards of nursing care in any perioperative nursing care in any perioperative setting.setting.

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