1. BY: Diana Blum RN MSN Metro Community College
OR Experience
BY: Diana Blum RN MSN
Metro Community College
In 2009, which are the latest statistics I could find… figures show that:
Total number of inpatient procedures
performed: 48.0 million
Cardiac catheterizations: 1.1 million
Coronary artery bypass graft: 415,000

2. Preoperative Begins with the scheduling of procedure
Ends at time of transfer to surgical suite
Places emphasis on safety and client education
The client’s readiness is critical to the outcome
Includes education and intervention to reduce anxiety and complications, and to promote cooperation
Communication and collaboration with the surgical team is essential to reach desired outcome
Baseline testing may me done here or prior to surgery day. Consent needs obtained before anesthesia is delivered.

3. Procedures Categorized by: Reason for procedure
Urgency of the procedure
Degree of risk
Anatomic location
GUIDELINES ON P.587

4. Types of Surgery Cosmetic Palliative Reconstructive Elective Urgent
Emergent
Curative
Exploratory
Diagnostic
Cosmetic is performed to enhance appearance.
Palliative is done for symptom alleviation.
Reconstructive is to rebuild tissue.---can anyone give an example of this that was in news over the past couple of years? New face, girl walks in propellar.
Elective is one that is scheduled for a non acute problem
Urgent is one that needs complete in a given time frame usually within 48 hours
Emergent is one that entails life or death
Curative obviously affects a cure for ailment
Exploratory is done to look around and determine next path to take
Diagnostic is done to confirm a dx.
If you are unsure of surgical suffixes look at pg 588.

5. Surgical Areas Preoperative holding area Quiet, calm transition
Equipment includes: 02, EKG machine, BP cuff, code cart
RN verifies that all relevant tests and documentation are completed prior to surgery
Abnormals reported to MD
Confirm NPO status
NPO needs confirmed on arrival to facility. It could postpone a surgery.
MAKE sure they void right before surgery!!!

6. ASSESSMENT Preoperative health evaluation
30 days before surgery, must be documented, clears pt for surgery
Pre op history and physical exam
Done by anesthesia provider
ASA classification, done with any type of sedation (pg 589)
Preop assess may be done 1 week before… tour or area , ekgs, lab, blood typing, etc
Baseline vitals are HUGE
Nutrition is also big because of the healing process post op.

7. Risk Factors Elderly Obesity Diabetes Heart conditions Renal failure
Dm increases heart risk and infection risk
RF increases heart risk and f/e
Elderly/copd/smokers have increased risk of atelectasis and pneumonia.

8. Assessment History Physical Psychosocial Laboratory Radiographic
Age, drug/ETOH use, meds, alternative meds, medical hx, surgery hx, anesthesia experiences, blood donations, allergies, family hx, type of surgery planned, education recv’d about perioperative period, support system
Physical
important to obtain baseline assessment, complete vitals, report abnormal findings to doctor
Psychosocial
Looks at anxiety level, coping ability, and support system
Anxiety and fear may influence the amount and type of anesthesia and affect ability to learn, cope, and cooperate
Laboratory
Provides a baseline for the client
Helps predict potential complications
Radiographic
Provides baseline and looks at size & shape of heart and lungs
Diagnostics
EKG- used as baseline. Looks for old MI, or other complications that could postpone surgery
Again LOOK FOR ABNORMALS they can hold up a surgery…BP issues, Dysrhymias, +UA
Why would ETOH use be important to know? It thins the blood
Why are drugs important? They affect metabolism and what can be given
Why herbal meds? They can affect a number of things for example fish oil thins the blood.

9. Example of preop form

10. Question Which diuretic can cause problems in surgery? A. lasix
B. hydrochlorothiazide
C. valium
D. benadryl

11. Lasix and hydrochlorothiazide may cause excessive respiratory depression resulting from an associated electrolyte imbalance
What electrolytes? Potassium and sodium

12. Nursing Diagnosis Disturbed sleep pattern r/t anxiety
Ineffective coping r/t impending surgery
Anticipatory grieving r/t effects of surgery
Disturbed body image r/t anticipated changes
Powerlessness r/t health care environment, loss of independence
Here are some nursing diagnoses for the preop period this is not an exclusive list. Others can apply as well.

13. Education
Doctor should explain purpose and expected results of surgery
Consent needs to be obtained prior to surgery. (if pt signs with an ‘X’ 2 witnesses must sign.
Client should ask questions if they don’t understand a term or procedure
NPO requirements needs to be explained
Preoperative preparations need to be explained (colon prep, or skin prep)
Client should understand post op exercises and techniques prior to surgery—I.S., etc.
Education is KEY. The more informed the less anxious they usually feel. Always keep cultural considerations in check see pg 598 for a discussion on those.

14. Informed Consent must be done prior to surgery
Procedure, risks and benefits need to be explained to the patient by the SURGEON
The patient must be competent to understand information
Consent for blood
Consent for anesthesia is separate
Pg 608.
Consent is usually good for hours depending on the facility. If they sign with a X then 2 witnesses must sign. Poa or guardian may also sign if pt unable. If you get phone consent 2 people need to witness. If life or death consent may be waived.

15. Legal Responsibilities
DNR
DNI
Must be clearly documented
Know your facility protocol.. Some facilities have it that they can be DNR on floor but not in OR.
Write NO on site not being operated on and yes on the correct site.

16. Surgical Prep Bowel prep Skin prep-shower, hair removal (clippers)
(see pg 610)
Preoperative meds
Antibiotic
Bowel: done for abd surgery to decrease intestinal bacteria
laxatives 1-2 days before low residue diet several days before, antibx, enemas nite before
Skin prep: CHG baths nite before and morning of to rinse off bacteria
Preop meds: antibx for infection prevention
Antianxiety to help relax
NPO to decrease aspiration

17. Tubes, drains, vascular access
Pt must be educated prior to surgery
Reduces fear
Tubes
Foley- monitors renal function
NG-used for abd surgery to decompress the stomach
Drains
Removes fluid for surgical site.
CT, JP, Hemovac, Orthopat
Vascular access
For anesthesia
For drugs and fluids

18. Respiratory education
Incentive spirometry
Encourages clients to take deep breaths every 1-2 hours after surgery
Usually 10x’s per hour or with each commercial break from a TV show
Deep breathing
Sit upright, feet firm on ground, gentle breath through mouth, exhale gently
Expansion breathing
Comfortable upright position, knees slightly bent, place hands on each side just above waist
Splinting
use pillow or towel and place over surgical site, take 3 deep breaths and clear then cough to loosen secretions
See chart 18-4 for more thorough instruction

21. DVT risk Obese >40 yrs old Have cancer
Immobile or decreased mobility
Leg fracture or trauma
History of DVT, PE, Varicose veins, or edema
Use oral contraceptives
Smoke
Decreased cardiac output
Get them antiembolism stockings
The clients with these have increased risk of SVT why?
Venous stasis is the answer.
That is why ted hose are worn and in or they are usually thigh highs.

22. Aka “sexy socks”

23. Anxiety reduction Distraction Promote rest Guided imagery
What is guided imagery?
Have the pt close their eyes and imagine something that would appeal to them. Like the beach, a concert, etc.
Also help to foster open ended questions.

25. Gerontological Considerations
Go over instructions slower
Have family present
Co-existing disease increases risk
Positioning
The coexisting conditions make the surgery riskier
Why is positioning important?
Easier to get to surg site, puts at injury risk
Culturally what can we do?
get interpretor, work around worship time if able, face bed toward mecca if able, respect beliefs.

26. Intra op
Urinary retention is a problem post op in some surgeries so we need to plan accordingly in the preop arena.

27. Nursing diagnosis Risk for infection Impaired skin integrity
Altered body temperature
Anxiety
Injury related to positioning and other hazards

28. Members
Surgeon
heads surgical team
Makes decisions related to surgical procedure
May need assistant
Surgical assistant (other doctor, surgical tech, resident, intern)
May hold retractors, suction wound, cut tissue, suture, and dress wounds depending on scope of practice and under supervision of physician
Anesthesia
Anesthesiologist or Certified Registered Nurse Anesthestist
Maintains airway
Monitoring circulation/respiratory status
Replace blood/fluid loss

29. OR nurses Holding area nurse Primary role is Circulating Nurse
Duties performed outside of sterile field
Scrub Nurse
Passes instruments, sponges in the sterile field
Perform surgical scrub
Very specialized role, most education is during orientation, not in nursing school.

30. Surgical Areas Operating Room Restricted area
Trend towards less invasive procedures (less scarring, quicker recovery, decreased length of hospitalization

31. Basic Guidelines for Surgical Asepsis
All materials in contact with the wound and within the sterile field must be sterile.
Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff.
Only the top of a draped table is considered sterile.
Items are dispensed by strategically to maintain sterility.
Movements of the surgical team are from sterile to sterile and from unsterile to sterile only.

32. Movement around the sterile field must not cause contamination of the field. At least a 1-foot distance from the sterile field must be maintained.
Whenever a sterile barrier is breached, the area is considered contaminated.
Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile.
Sterile fields are prepared as close as possible to time of use.
ure=related

33. Question
true or false.
To maintain surgical asepsis, the nurse knows that the sides and top of a draped table is considered sterile.

34. Answer
False.
Rationale: Sterile drapes are used to create a sterile field. Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back.

35. Infection
Anyone with open wound, cold, or any infection should not participate in surgery
Jewelry should be minimal
Hands of surgical staff are usually cultured every 3-6 months to determine possible nosocomial (hospital acquired) infections
Like what---staph or strep

36. Time out procedure
Nurse asks pt to confirm procedure and is verified with consent form
Patient verifies the right site and surgeon
2 patient identifiers
Site mark
“Time out”
Name, procedure, site, document
See pg. 612

37. Anesthesia
0&NR=1

38. Anesthesia
Def: induced state of partial or total loss of sensation, occurring with or without loss of consciousness.
Purpose: block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and sometimes achieve controlled level of unconsciousness
Choice depends on: type and duration of procedure, area of body, safety issues, emergency, pain management after surgery, last meal or liquids or drugs
TABLE ON PAGES

39. General
Definition: reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system
Depress CNS
Results in analgesia (pain relief), amnesia (memory loss), and unconsciousness with loss of muscle tone and reflexes
Used in head, neck, upper torso and abd surgeries

40. Stages of general 1:sedation administered
Induction and LOC, decreased sensation
Warmth, dizziness, noises exaggerated
2: excitement/delirium
LOC and relaxation, regular breathing
Pupils dilate, HR increases, may need to restrain pt
Do not touch pt
3: operative anesthesia
Muscle relaxation, depressed vitals
Unconscious, maintained for hours
4:danger = Medullary Depression
Depressed vs, respiratory failure
Too much anesthesia, cyanosis
Emergence: recovery from anesthesia

41. Types of general Inhalation: most controllable Fast acting
Passes through vaporizer
Depresses CNS
Ex: Nitrous Oxide

42. IV: rapid and pleasant Induce and maintain anesthesia
Anesthetics Opiods
Etomidate Fentanyl
Valium Morphine
Versed
Diprivan
Reversal agent for opoids=Narcan (0.2mg)
Reversal agent for Benzos = Romazicon(0.2mg)

43. Muscle relaxants Affect skeletal muscle Administered before intubation
Assess with nerve stimulator
Succinylcholine, Tracrium, Vecronium
Reversal agent= Neostigmine (0.5-2mg

44. Balanced: minimal disturbance to function, used with elderly and high risk
Regional (Spinal, Epidural, Peripheral nerve block)~ gag and cough stay intact
block transmission of sensory impulses
Does not depress respirations
Local injection of med
With balanced smaller doses are used.
Complications of regional: HA
Hypotension
Meningitis
Hematoma at site
Nerve damage

45. Types of Regional Anesthesia
Spinal
Local anesthetic injected into subarachoid space, directly into CSF
“Blocks” at level of spinal cord (sensory and motor)
Epidural
Local anesthetic into epidural space
Peripheral nerve block
Anesthesia of a certain area
No systemic effect

46. Intraoperative Complications
Nausea and vomiting
Anaphylaxis
Hypoxia and respiratory complications
Hypothermia
Dysrhymias
Malignant hyperthermia
Disseminated intravascular coagulation (DIC)
Anaphylaxis allergy to substance
Hypoxia= decreased sats compromised lung sounds
Hypotherm. Is decreased temp
Malignant hyper…muscle disorder genetically transferred. Temp >104, tachy low bp

47. Malignant Hyperthermia
Life threatening
Predisposition is genetic
causes increased calcium and potassium levels in skeletal muscles
Immediate reaction or several hours later
s/s: tachycardia, dysrhythmias, muscle rigidity (jaw, face), hypotension, tachypnea, mottling, cyanosis, myoglobournia (muscle proteins in urine),
*increase in CO2 and decrease sat
Care: stop agent, intubate, give dantrium to reverse, check ABG, cooling techniques, monitor core temp, EKGs, insert foley, hydrate, ICU for at least 24 hours
Chart 26-3

48. Manifestations Hypoxia Hyperthermia****THIS IS A LATE SIGN****
Dysrhythmias
Hypotension
Early signs:
contracture of jaw
Sinus tach
Increase in expiratory CO *Pg. 630 *

49. Complications continued
Overdose: can occur if metabolism and drug elimination are slower (ht, wt, and allergies are vital to know before administration)
Unrecognized hypoventilation: failure to exchange gases can lead to cardiac arrest, permanent brain damage, and death. Vital to use end tidal carbon dioxide monitor to confirm the exchange

50. Intubation complication
Broken or chipped teeth
Swollen lip
Vocal cord trauma

51. Question
Malignant hyperthermia usually manifests within what time frame after induction of anesthesia?
5 minutes
10–20 minutes
30 minutes
45 minutes

52. Answer
10–20 minutes
Rationale: Malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia. It can also occur during the first 24 hours after surgery.

53. Local Numbing agent is used Mentally alert
Complications: potential cardiac depression, toxic reaction, edema, blurred vision, inflammation, etc. see
Provides a numbing sensation to the site of interest like with pacemakers and stitches.

54. Types of local Topical Infiltration: directly into wound or lesion
Blocks:
Field: injections around work site (lidocaine, novocaine)
Nerve: injection into or around nerve in involved area- used for chronic pain relief
Spinal: injection of agent into CSF in the subarachnoid space-absorbed rapidly
Epidural: placed in epidural space-may affect breathing
Example of topical is tetracaine
Infiltration example is novocaine
Nerve is done for shoulder surg
Epidural for ob stuff

56. Moderate (Conscious) Sedation
Minimally depressed LOC
Pt able to maintain airway
Pt responds to physical and verbal stimuli
Twilight or translike
Quickly recovers

57. Moderate (Conscious) Sedation
As a nurse, what do you need to have available at the bedside?
What medications might be given?
What monitoring/assessments?
What types of procedures?
#1 airway tele
#2 versed fentanyl
#3 airway vs
#4 colonoscopy egd tee

58. Potential Adverse Effects of Surgery and Anesthesia
Allergic reactions or drug toxicity
Cardiac dysrhythmias
Over sedation or Under sedation
Trauma: laryngeal, oral, nerve, and skin, including burns
Hypotension
Thrombosis
See Chart 19-1
qB4EWlZg
Anesthesia awareness: they feel everything but cant move

59. Gerontologic Considerations
Elderly patients are at increased risk for complications because of:
Pre-existing conditions.
Aging heart and pulmonary systems.
Decreased homeostatic mechanisms.
Changes in responses to drugs because of changes such as decreased renal function, etc.

60. Nursing diagnosis Risk for injury r/t positioning
Impaired skin integrity r/t surgical incision
Risk for infection

61. Important to remember
Always know client’s wishes about life sustaining measures because they apply in the OR as well
However some facilities/doctors require that the surgical client that is DNR on unit is full code in OR.
Always know the allergies and reactions
Always know current lab values because they could postpone surgery
Know the client’ s baseline vitals to monitor for complications
Patient identification
Correct informed consent
Verification of records of health history and exam
Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient
Verification and accessibility of blood

62. Positioning Accommodates access Surgical view
Maintain skin integrity (pressure ulcers)
Injury to nerves may happen
Prevent injury
Complications:
Compromised respiratory status, pressure ulcers, injury to nerves

63. Surgical positions Supine Trendelenburg Prone Lateral Jackknife
lithotomy

64. Bariatrics Deals with causes, prevention, and treatment of obesity
First line: diet, exercise, behavior
therapy, & antiobesity drugs
BUT HAS ONLY SHORT TERM
SUCCESS IN MANY CASES

65. Antiobesity drugs:
Orlistat (approved Feb ’07)
- reduces absorption of fat by inhibiting pancreatic lipase
Metformin
Byetta (delays gastric emptying)

66. Bariatric Surgery Roux en Y: most commonly performed
- least likely to result in nutritional
deficiencies
- small bowel is divided & arranged
into a “y” and attached to the small
stomach pouch
- pt feels fullness rapidly after eating

67. Post op
Starts at the completion of surgery and transfer to PACU or ICU
Stabilize VS, maintain airway
Prepare pt for discharge
To work here in-depth knowledge of the following areas needed: pharm, pain management, and procedures, good assessment skills, decision maker in critical situations

68. Assessment Cardio Telemetry, ekgs, vitals, pulses, homans, Neuro
LOC, motor response, orientation, arousal
Fluid and electrolyte
I/O, hydration, IVF, acid base
Renal
Output, urine retention is common if no foley Gi
N/V, peristalsis, monitor for ileus, NG tube output if indicated
Skin
Monitor wound, drainage, drains, dressings,
Vitals are vital
Usually q15” x4, q30” x4, q1hr x4, q2hr x4, then q4hr
Respiratory status
Airway management, lung sounds, muscle use, snoring, stridor (high pitched crowing)
Monitor PAIN
Laryngospasms could occur causing aireway to be closed—open it sxn it 02 intubate etc

69. Early infection can be indicated on increase in band cells of the WBC differential (left shift)
Get culture
Notify MD
Monitor ABGs and CMP
What does the shift mean?
there is an increase in immature blood cells. This happens to attemp to ward off a active infection. Think of it like a bird the mama is kicking the babies out of the nest before it is time.

71. Aldrete Post Anesthesia Recovery Score (PARS)
Numerical scoring system to eval PACU patients
Based on activity, Respirations, Circulation, Consciousness, O2 Sats
Ranges from 0 to 10, 10 is the best
Score when arrives in PACU, every 30 min until 8 or higher is achieved
Score also done at discharge

72. Nursing diagnosis

73. Impaired Gas Exchange Open airway
Breathing pattern improved over baseline
Adequate O2 saturation
Provide supplemental oxygen
Artificial airway if patient is minimally responsive
Cough deep breath, IS

74. Risk for Imbalanced Fluid Volume
Adequate hemostasis
Normal fluid and electrolyte balance
Monitor hourly for postop bleeding
Mark drainage on dressing, monitor for enlargement
Monitor for possible drainage beneath patient
Monitor for internal bleeding
Monitor for signs of dehydration, fluid overload

75. Risk for Decreased Cardiac Output
Rhythm, cardiac output
BP, heart rate consistent with baseline
Monitor for sinus tachycardia/bradycardia, identify and treat cause
Monitor for hypotension; IV fluids, patient positioning
Monitor for hypertension, identify and treat cause

76. Risk for Imbalanced Body Temperature: Hypothermia
Normal core temperature
Monitor for core temperature <36°C (96.8°F), shivering, patient report of feeling cold
Risk factors: patient history, length of surgery, cold solutions
Blankets, clothing, ambient temp
Treat with active warming, meds

77. Pain Physiological and psychological effects
Delayed ambulation, diminished functioning
Monitor for pain management and respiratory depression
PCA, PCEA: monitor for pain relief, untoward effects
Monitor sensory level of the epidural

78. Anxiety Can increase morbidity and mortality, length of stay
Affects VS, depresses immune system, delays healing
Implicated in heart problems, postop pain
Individualized care plan based on patient preferences
Frequent reassurance about condition and progress
Maintain a calm, quiet, restful environment

79. Drains see chart 27-6 Hemovac JP Penrose
With the chest tube the oasis is the dry type the ocean is the wet type and it is important to monitor drainage for color amount airleak etc.
Hemovac JP
Penrose

80. Types of wound healing Phases of healing 1 inflammatory
2 proliferative
3 maturation
Types of healing
first: scar formation is minimal cover with dry sterile dressing
second: granulation occurs in abscessed wound-scar forms
third: used for deep wounds. Scar is deep and wide pack with gauze.

81. Post-Op Complications
Evisceration
Dehiscence
SSI
Atelectasis
Pneumonia
ileus
Urinary retention
DVT

82. Dehiscence Partial or complete separation of wound layers
Wound is open
Prevention?
Tx is surgery or dressing

83. Evisceration Complete separation of wound layers
Protrusion of internal organs
Usually occurs 5-10 days post-op
Prevention?
Surgery. Know the postion to place them…and what to do with the dressing
Both are emergencies. Call for help get pt to bed. Place supine with knees bent. Cover wound/organ with steril towels soaked in normal saline. Keep moist.. DO NOT push the organs in. VS q5 minutes. MOST important CALL the doctor.

84. Dehiscence Evisceration Complications on chart 27-4

85. Surgical Site Infections (SSI)
Aseptic technique
Most infections are caused by exogenous organisms
Surgical wound classification (pg. 636)
Risks:
Obesity, smokers, malnourishment

86. Atelectasis and Pneumonia
Collapse of alveoli
Mucus accumulates
Leads to fever and hypoxia
Incidence of post op pneumonia 15%
High fowlers
IS, CDB
Ambulate

87. Gastrointestinal N/V Flatus Bowel sounds
Ileus-hypoactive bowel, delay in peristalsis

88. Urinary Retention Foley cath Must void within 6-8hrs
Anesthesia causes relaxation, retention
May have swelling from certain procedures

89. DVT
LWM- Heparin or lovonox
SCD
TEDS
Ambulation
Leg exercises