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Intraoperative Care
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Physical Environment Surgical suite Controlled environment
Designed to minimize spread of infections Allows smooth flow of patients, personnel, and instruments/equipment
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Physical Environment Unrestricted areas
Personnel in street clothes interact with those in scrubs Holding and information areas
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Physical Environment Semi-restricted areas
Peripheral support areas and corridors with only authorized people Must wear surgical attire and cover all head and facial hair
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Physical Environment Restricted areas Operating rooms
Scrub sink areas and clean core Masks required
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Physical Environment Holding area
Waiting area inside or adjacent to surgical area Final identification and assessment Minor procedures performed Friends/family allowed
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Physical Environment Operating room
Geographically, environmentally, bacteriologically controlled Restricted in inflow and outflow of personnel Preferred location is next to post- anesthesia care unit
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Surgical Team Perioperative nurse Prepares room with team
Patient advocate throughout surgical experience
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Surgical Team Circulating nurse Not scrubbed, gowned, or gloved
Remains in unsterile field Documents
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Surgical Team Scrub nurse Follows designated scrub procedure
Gowned and gloved in sterile attire Remains in sterile field
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Surgical Team Surgeon Physician who performs the procedure
Responsible for: Preoperative medical history Physical assessment Patient safety
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Surgical Team Surgeon’s assistant can be physician or RN who functions in assisting role Holds retractors Assists with hemostasis and suturing May perform portions of procedure under direct supervision
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Surgical Team Anesthesia care provider Administers anesthesia
Anesthesiologist or nurse anesthetist Maintenance of physiologic homeostasis throughout intraoperative period
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Nursing Management Before surgery Psychosocial assessment
Physical assessment Chart Review
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Nursing Management Chart review History and PE Urinalysis CBC
Serum electrolytes Chest x-ray ECG
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Nursing Management Chart review Diagnostic tests (i.e., CT scan)
Pregnancy testing Surgical and blood transfusion consent Allergies Blood type and crossmatch
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Nursing Management Room preparation
Surgical attire worn by all persons entering OR suite Electrical and mechanical equipment checked for proper functioning
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Nursing Management Aseptic technique practiced with placing instruments Counts Delineation of team members
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Nursing Management Basic aseptic technique
Center of sterile field in surgical incision Only sterilized items in sterile field Face shields Caps, gloves, aprons, eyewear
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Nursing Management Positioning of patient
Accessibility of operative site Administration and monitoring of anesthetic agents Maintenance of airway Correct skeletal alignment
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Commonly Used Intra Op Positions
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Nursing Management Prevent pressure on nerves, skin over bony prominences, eyes Provide for adequate thoracic excursion Prevent occlusion of arteries and veins Provide modesty in exposure Recognize and respect needs such as pain or deformities
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Nursing Management Prevent injury
Patient will not feel pain impulses due to anesthesia Secure extremities Provide adequate padding and support
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Classification of Anesthesia
General anesthesia Local anesthesia Regional anesthesia Conscious sedation
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Classification of Anesthesia
General Anesthesia Loss of sensation with loss of consciousness Skeletal muscle relaxation Analgesia
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Classification of Anesthesia
General anesthesia IV induction agents Induce pleasant sleep Rapid onset Inhalation agents Enter body through alveoli Rapid excretion by ventilation
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Classification of Anesthesia
Adjuncts to general anesthesia Opioids Pre-op: Sedation and analgesia Intra-op: Induction & maintenance Post-op: Pain management Respiratory depression
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Classification of Anesthesia
Adjuncts to general anesthesia Benzodiazapines Premedication for amnesia Induction of anesthesia Conscious sedation Supplemental IV sedation during local and regional anesthesia Anxiety and agitation
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Classification of Anesthesia
Adjuncts to general anesthesia Neuromuscular blocking agents Facilitate endotracheal intubation Relaxation/paralysis of skeletal muscles Interrupt transmission of nerve impulses at neuromuscular junction
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Classification of Anesthesia
Adjuncts to general anesthesia Antiemetics Prevent nausea and vomiting associated with anesthesia
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Classification of Anesthesia
Local anesthesia Loss of sensation without loss of consciousness Topically Intracutaneously Subcutaneously
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Classification of Anesthesia
Spinal anesthesia Injection of agent into CSF in subarachnoid space Usually below L2 Autonomic, sensory, and motor blockade May become hypotensive from vasodilation
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Classification of Anesthesia
Epidural block Injection of agent into epidural space Does not enter CSF Binds to nerve roots as they enter and exit the spinal cord Patient can remain fully conscious
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Classification of Anesthesia
Observe closely for signs of autonomic nervous system (ANS) blockade Bradycardia Hypotension Nausea/vomiting Decreased incidence of headache associated with spinal anesthesia
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Classification of Anesthesia
Regional anesthesia Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked with administration of local anesthetic
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Classification of Anesthesia
Conscious sedation Minimally depressed level of consciousness with maintenance of patient’s protective airway reflexes
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Additional Anesthetic Considerations
Controlled hypotension Decrease amount of expected blood loss by lowering blood pressure during administration of anesthesia
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Additional Anesthetic Considerations
Hypothermia Deliberate lowering of body temperature to decrease metabolism Reduces demand for O2 and anesthesia
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Catastrophic Events in the OR
Anaphylactic reactions Manifestations may be masked by anesthesia Vigilance and rapid intervention essential
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Catastrophic Events in the OR
Malignant hyperthermia Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium Rare metabolic disease Hypermetabolism of skeletal muscles → muscle contracture, hyperthermia, hypoxemia, lactic acidosis,cardiac collapse
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Catastrophic Events in the OR
Malignant hyperthermia Tachycardia Tachypnea Hypercarbia Ventricular arrhythmias Rise in body temperature NOT an early sign Can result in cardiac arrest and death
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