Intraoperative Nursing Management

Preoperative Nursing Management CONDUCT A NURSING ASSESSMENT PROVIDE PREOPERATIVE TEACHING PERFORM METHODS OF PHYSICAL PREPARATION ADMINISTER MEDICATIONS ASSIST WITH PSYCHOSOCIAL PREPARATION COMPLETE THE SURGICAL CHECKLIST

PREOPERATIVE CHECKLIST History and physical examination. Name of procedure on surgical consent. Signed surgical consent. Laboratory results. Client is wearing an identification bracelet. Allergies have been identified. NPO. Skin preparation completed. Vital signs assessed.

Jewelry removed. Dentures removed. Client is wearing a hospital gown and hair cover. Client has urinated. Location of IV site, type of intravenous solution, rate of infusion is identified. The prescribed preoperative medication has been given.

Intraoperative Nursing Care Intraoperative- Begins when the patient is transferred into the operating room and ends with his admission to the post anesthesia recovery room (PARR) or post anesthesia care unit (PACU).

Nursing Interventions - Communicating plan of care - Identifying nursing activities - Establishing priorities - Coordinate care with team members - Coordinate supplies and equipment - Control environment - Document plan of care

Surgical team The Patient Surgeon Anesthesiologist Scrub Nurse Circulating Nurse OR techs

The Patient As the patient enters the operating room, he or she may feel relaxed and prepared, or fearful and highly stressed. These feelings depend very much on: - The amount and timing of preoperative sedation - The patient’s level of fear and anxiety. - Fears about loss of control, the unknown, pain, death, changes in body structure or function. - Disruption of lifestyle all may contribute to a generalized anxiety.

These fears can increase the amount of anesthetic needed. The level of postoperative pain, and overall recovery time.

The patient is also subject to several risks. - Infection, failure of the surgery to relieve symptoms, - Temporary or permanent complications related to the procedure or the anesthetic, and - Death are uncommon but potential outcomes of the surgical experience

Intraoperative Phase- Surgical team Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.

Intraoperative Phase- Surgical team Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; Maintenance of pt’s safety and integrity. Observation of the scrubbed team for breaks in the sterile fields; Provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

Surgical team Circulating Nurse - responsible for: Creating a safe environment, Managing the activities outside the sterile field, Providing nursing care to the patient.

Circulating Nurse cont. Documenting intra-operative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count And communicating relevant information to individual outside of the OR, such as family members.

Surgical team Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons. Other personnel- pathologist, radiologist, perfusionist.

Surgical team Nursing Roles: Staff education Client/family teaching Support and reassurance Advocacy Control of the environment Provision of resources Maintenance of asepsis Monitoring of physiologic and psychological status

Surgical asepsis Ensure sterility Alert for breaks (how)?

The surgical environment The surgical environment is known for its stark appearance and cool temperature. The surgical suite is behind double doors, and access is limited to the authorized personnel.

The surgical environment To provide the best conditions for surgery, the OR is suited in a location that is central to all supporting services (pathology , radiology, and laboratory). The OR has special air filtration devices to screen out contamination items, dust, and pollutant.

The surgical environment The surgical area divided into three zones: 1- unrestricted zone: where street clothes are allowed. 2- Semirestricted zone: where attire consists of scrub clothes and caps. 3- restricted zone: where scrub clothes , masks are worn.

Health hazard associated with the surgical environment *Exposure to the blood and body fluids: - double gloving is routine, at least in trauma surgery. - goggles, to protect against splashing. *Laser risk, exposure to the eye and skin beam, and inhalation of the laser plume ( smoking and particulate matter).

Health hazard associated with the surgical environment cont. - Nurses and Intraoperative personnel working with lasers must have eye examination. - Special protective goggles are worn. Smoke evacuators are used in some procedures to remove the laser plume from the operative field Latex allergy: Identification of the patient with latex allergy.

Perioperative Nursing Care Types of Anesthesia Regional Local Nerve block Epidural Spinal General

Anesthesia General anesthesia consists of four stages, each associated with specific clinical manifestation. Anesthesia is a state of narcosis ( sever central nervous system depression produced by pharmacological agents).

Types of anesthesia cont. 1. General Anesthesia (inhaled or intravenously) refers to drug – induced depression of the central nervous system that produces analgesia, amnesia and unconsciousness (affects whole body).

Stages of Anesthesia *Stage 1: patient feel detachment warmth, dizziness, though still conscious. - The nurse avoid unnecessary noises or motion. *Stage 2: Excitement: as struggling, shouting, singing , laughing or crying. - the patient should be restrained - anesthetic is administered smoothly.

Stages of Anesthesia *Stage 3: Surgical Anesthesia: the patient is unconscious and lies quietly on the table. This stage may be maintained for hours .

Stages of Anesthesia *Stage 4: Medullary Depression: this stage is reached when too much anesthesia has been administered . - Respiration become shallow. - Pulse weak and thready. - Pupils become widely dilated and no contract in response to light. - Cyanosis developed. - Death rapidly follow. If this stage develop, the anesthetic is discontinued immediately.

Types of anesthesia 2. Regional anesthesia is a form of local anesthesia that suspends sensation and motion in body region or part; the client remains awake.

Types of anesthesia 3. Spinal Anesthesia is local anesthesia injected into the subarachniod space at lumbar level between L4 and L5 to block nerves and suspend sensation and motion to the lower extremities, perineum, and lower abdomen.

SPINAL ANASTHESIA

Spinal Anesthesia Indications -Surgical procedures below the diaphragm -patients with cardiac or respiratory disease Advantages -mental status monitoring -shorter recovery Disadvantages -necessary extra expertise -possible patient pain Contraindications -coagulopathy -uncorrected hypovolemia

Spinal Anesthesia Involved medications -lidocaine -bupivacaine -tetracaine Patient assessment -continuous heart rate, rhythm, and pulse oximetry monitoring -level of anesthesia -motor function and sensation return monitoring

Spinal Anesthesia Complications -hypotension -bradycardia -urine retention -postural puncture headache -back pain

OPERATION POSITIONS

ENDOTRACHEAL INTUBATION

Nursing role in recovery room Level of postoperative care a patient requires is determined by: - Degree of underlying illness. - Preoperative complications. - Duration and complexity of anesthesia and surgery. - Risk of postoperative complications. Patient must be carefully evaluated to determine which level of postoperative care is most appropriate.

Postoperative care unit Recovery from anesthesia can range from completely uncomplicated to life-threatening. Must be managed by skilled medical and nursing personnel. Anesthesiologist plays a key role in optimizing safe recovery from anesthesia.

PACU LOCATION Should be located close to the operating suite. Immediate access to x-ray, blood bank, blood gases and clinical labs. An open ward is optimal for patient observation, with at least one isolation room. Piped in oxygen, air and vacuum suction. Required good ventilation.

PACU equipment Automated BP , pulse ox., ECG, and intravenous supports should be located at each bed. Bed side supply storage, suction, and oxygen flow meter at each bed-side. Capability for arterial and CVP. Monitoring. Supply of emergency equipment, crash chart, Defibrillation.

PACU staffing One nurse to one patient for first 15min. Of recovery. Then one nurse for every two patients. The anesthiologist responsible for the surgical anesthesia remains responsible for managing the patient in the PACU.

Admission history Preoperative history. Intraoperative factors. - procedure - type of anesthesia. - EBL (estimated blood loss). - UO ( urinary output). Assessment and report of current status. Postoperative instructions.

INITIAL POSTOPERATIVE ASSESSMENTS Level of consciousness. Vital signs. Effectiveness of respirations. Presence or need for supplemental oxygen. Location of drains and drainage characteristics. Location, type, and rate of intravenous fluid. Level of pain and need for analgesia. Presence of a urinary catheter and urine volume.

Potential Intraoperative Complications Nausea & vomiting, Anaphylaxis, Hypoxia, Hypothermia, Malignant hyperthermia, And disseminated intravascular coagulopathy.

NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses for the patient with DIC may include the following: Risk for deficient fluid volume related to bleeding Risk for impaired skin integrity related to ischemia or bleeding. Potential for excess fluid volume related to excessive blood/factor component replacement • Ineffective tissue perfusion related to microthrombi • Anxiety and fear of the unknown and possible death

POST OPERATIVE COMPLICATIONS

Related Questions True and false question. A sterile field is an area free of microorganisms that is able to receive sterile and nonsterile items. T F.

Related Questions MCQs: A- In reviewing the chart of a patient about to undergo general anesthesia, which of the following is the greatest risk factor? The patient who: 1- expresses anxiety about the upcoming procedure. 2- ate a snack within the last three hours. 3- smoke and states his last cigarette was 24 hours ago. 4- has a history of hypertension controlled by diet and exercise.

Related Questions b- The nurse is caring for a patient who is perioperative. Which of the following is the priority nursing intervention utilized to prevent infection in this client? 1- preparation of the skin overlying the surgical site. 2- maintenance of hemodynamic status. 3- maintenance of client’s temperature. 4- determination of estimated blood loss.

Related Questions C- The nurse is caring for a patient in the immediate postoperative period. Which of the following would indicate that the client is becoming hypovolemic? 1- a diastolic blood pressure of 100 mm Hg. 2- the client complains of excruciating pain. 3- the client complains of anxiety. 4- blood loss of 500 ml.

Related Questions D- The nurse is caring for a client postoperatively. Which of the following would indicate that the client has a compromised airway? The client 1- complains of anxiety. 2- complains of pain. 3- has a pulse oximetry reading of 90%. 4- is slightly cool and clammy.

Related Questions E- The nurse is caring for a client postoperatively who has become hypothermic. The nurse’s best action would be to: 1- position the client in a left lateral position. 2- administer an analgesic. 3- remove clothing saturated with blood. 4- monitor the intake and output.

Related Question F- The nurse is obtaining a nursing history from a client suspected to be at risk for malignant hyperthermia, which of the following should the nurse assess first to elicit the most accurate risk assessment? 1- Previous history of complications associated with surgery. 2- Over-the-counter medication usage. 3- History of unexplained fever. 4- Drug allergies.

Related Question G- Which of the following should the perioperative nurse monitor when evaluating the presence of ineffective thermoregulation in a client? 1- Cardiac rhythm. 2- Blood pressure. 3- Oxygen saturation level. 4- Temperature.

Related Question H- Which of the following is the priority nursing intervention that the nurse should perform for a client in the immediate postoperative period? 1- establish a patent air way. 2- Maintain adequate blood pressure. 3- Establish level of consciousness. 4- assess level of pain.

Related Question I- a client admitted to the post anesthesia care unit after abdominal surgery the incision site complains of “feeling pop” and a gush of warm fluid at incision site the nurse conclude that the client has experienced a wound dehiscence. The priority nursing interventions would be to: Select all that apply: ( ) 1. position the client in a supine position. ( ) 2. obtain a complete set of vital signs. ( ) 3. cover the incision with a sterile dressing. ( ) 4. apply oxygen via nasal cannula at 8 L/min. ( ) 5. contact the surgical team. ( ) 6. increase the I.V. fluid rate.

Reference Brunner , Medical-Surgical Nursing . Chapter 19 . Page 417-434.