perioperative & intraoperative nursing. perioperative nursing entire operative process which...

Perioperative & Intraoperative Nursing

Perioperative Nursing Entire operative process which includes: Preoperative Before surgery Intraoperative During surgery Postoperative Following surgery

Surgery The branch of medicine concerned with diseases and trauma requiring operative procedures Classification of surgical procedures Admission Status Ambulatory or outpatient Same-day admit Inpatient Seriousness Major Minor

Urgency Elective Patients choice Urgent Necessary for patients health Emergency Must be done immediately to save life or preserve function

Purpose Diagnostic Confirm diagnosis Ablation Excision or removal of diseased body part or removal of a growth or harmful substance Palliative Relieves or reduces intensity of disease symptoms Reconstructive Restores function or appearance to traumatized or malfunctioning tissue Transplant Replaces malfunctioning organs or structures Constructive Restores function lost or reduced as result of congenital anomalies

Can your patient tolerate surgery? Age Young and older patients metabolic needs such as temperature changes, cardiovascular shifts, respiratory needs, and renal function, may not respond to physiological changes quickly Elderly considerations 86% of elderly have at least one chronic disease Cardiovascular Respiratory Renal and Liver impairment Short term memory loss affects Confusion and delirium Fragile Integumentary system Thermoregulation issues

Physical condition Surgical effects on Body Systems Coexisting health problems especially Diabetes Nutritional factors "Nitrogen Balance" expresses the balance between anabolism and catabolism Measured by assessing dietary intake vs. urinary output (as urea)

"Positive" nitrogen balance (net storage of nitrogenous compounds): childhood growth pregnancy muscle building healing "Negative" nitrogen balance (net breakdown of stored nitrogenous compounds): illness starvation amino acid deficiency wounds

Socioeconomic and cultural needs Social Economic Religious Ethnic Cultural Education and experience Life experiences Educational level

Fear Evidence that a relationship exists between preoperative fear and postoperative behavior More anesthesia required More postoperative pain medication needed Slower speed of recovery Patient enters an environment in which they have very little control -needs to feel free to ask questions.

Common Fears Fear of loss of control (anesthesia) Fear of the unknown (outcome, lack of knowledge) Fear of anesthesia (waking up) Fear of pain (pain control) Fear of death (surgery, anesthesia) Problem with minor surgery, as well as major Fear of separation (support group) Fear of disruption of life patterns (ADLs, work) Fear of detection of cancer

Everyone has an accustomed role, and they are used to doing for themselves. It may be frustrating, painful, embarrassing, etc. to have others help.

Intra-operative Nursing

Errors That Can Occur Patient misidentification Incorrect procedure Foreign bodies left in patient Patient burns Falls or positioning errors Improper handling of specimen Incorrect drugs or administration

Harm secondary to use of defective equipment/instruments Loss of or damage to patients property Harm secondary to a major break in sterile technique Exceeding authority or accepted functions

There are Hazards! Physical: noise, ionizing radiation, electricity, injury to body, fire, explosion Biologic: laser/electrosurgical plume, pathogens, latex sensitivity, sharps injury Chemical: disinfecting agents, waste anesthetic gas, vapors and fumes Methyl methacrylate(used in the fields of medicine and dentistry to make prosthetic devices and as a ceramic filler or cement)

Fire/explosion can result from: Source of ignition Spark from metal hitting metal Oxygen Flammable materials Gas, vapor, liquid (ethyl alcohol) Electrical Ionizing radiation Static electricity Electrical burns

Sterile Environment Gown Gloves Mask Hair cover Shoe covers Movement Must not compromise the sterile field Sterile to sterile Nonsterile to nonsterile Sterile individuals keep within sterile area Scrub NurseCirculating Nurse Anesthesiologist

A lot of thought goes into the design of operative suites

Establishing the Sterile Field Mask must be applied prior to creation Sterile items on the sterile field Established far away from doors and high traffic areas Kept in constant view

Establishing the Sterile Field Check packaging for integrity Unfold First flap away from you Second flap toward you Reposition and open third flap Move to opposite side to open fourth flap

Sterile field: In front of you, above the waist and below the shoulder. Carry sterile equipment away from your body.

Sterile Work Table Ready to Go Even the Anesthesiologist is unwelcome in the sterile field!

Instrument count sheet always included in instrument tray

Surgical Ward: Bastion of Fashion Patients must dress appropriately ( getting a pediatric patient through induction can be tricky)

Shoes need to be covered and grounded

If Cleanliness is next to Godliness, this must be Heaven Circulating Nurse Preparing Sterile Gowns and gloves

Surgical Hand Scrub Attacking the nails first !

10 Strokes per plane

Rinse from hand to elbow

Dry with Sterile Towel so Lovingly Laid out by the Circulating Nurse

Gowning Sterile

Howd he do that??!

Waiting for his favorite nurse!

Teamwork !

The Gas Man!!

Anesthesia plays a major part in surgery and pain management. Its action interferes with nerve conduction so that the sensation of pain is not perceived by the brain Two major classes General Regional Local Anesthesia Conscious Sedation

Anesthesia evaluation Status I - A healthy patient Status II - Patient with mild-to-moderate systemic disease (e.g., anemia, morbid obesity) Status III - Patient with severe systemic disease that limits activity but not to the point of incapacitation (eg, healed myocardial infarction, diabetes with vascular complications) Status IV - Patient with incapacitating systemic disease that is life-threatening (eg, advanced hepatic or renal insufficiency) Status V - Moribund patient who is not expected to survive (eg, major cerebral trauma, massive pulmonary embolus)

Drug Interactions Antibiotics Potentiate the action of anesthetic agents Anticholinergics Increase the potential for confusion Anticogulants Increase the risk for hemorrhaging Inquire into use of ASA and NSAIDS within 48 hours of surgery because of anti-platelet factor Anticonvulsants Long-term use can alter the metabolism of anesthetic agents Antidepressants Potentiate lowering of Blood Pressure

Antidysrhythmics Reduce cardiac contractility and impair cardiac conduction during anesthesia Antihypertensive Interact with anesthetic agents and cause bradycardia, hypotension and impaired circulation Corticosteroids Cause adrenal atrophy and reduce the bodys ability to withstand stress, Need a dosage adjustment prior to surgery Diuretics Potentiate electrolyte imbalances after surgery Herbal Substances These can interact with anesthesia and cause a variety of adverse effects. These substances need to be stopped at a specific point of time before surgery

General Anesthesia How does it work Four stages Stage One: Analgesia -analgesia or a loss of pain sensation -remains conscious and can carry on a conversation. Stage Two: Excitement -experiences delirium or become violent -elevated blood pressure and respirations -stage is typically bypassed by administering a barbiturate, such as sodium pentothal, before the anesthesia

General Anesthesia Stage Three: Surgical Anesthesia -skeletal muscles -breathing becomes regular -eye movements slow, then stop, and surgery can begin. Plane 1: Muscle tone decreases; eyelid, gag and swallow reflexes are lost Plane 2: Muscle tone continues to decrease, pauses occur between respiration and there is a slight change in the pupils Plane 3: Markedly decreased muscle tone and pupil dilation Plane 4: Widely dilated pupils and do not respond to light, intercostal muscles are paralyzed resulting in respiratory paralysis; pulse and blood pressure decrease. Stage Four: Medullary -paralysis, respiratory centers in the medulla oblongata cease to function -death can result if the patient cannot be revived quickly -stage should never be reached

Balanced Anesthesia Characteristics (uses inhalation and injection) Hypnosis Amnesia Muscle relaxation Relaxation of the neurological reflexes with minimal alteration in physiological function Effective and controlled level of anesthesia that is safe especially for the elderly clients and those at high risk for pulmonary problems Goal: Pass clients through stages of anesthesia with minimal side effects

Induction of Anesthesia Generally by IV injection of an ultrashort-acting barbiturates Theopental sodium Methohexital sodium Tends to depress the circulatory and respiratory systems as well as the CNS Ketamine Nonbarbituarate Produces analgesia too Emergence reaction include confusion, excitement and irrational behavior which can be controlled by IV diazepam (Valium)

Etomidate (Amidate) Nonbarbituate Does not produce cardiovascular or respiratory depressant effects. Midazolam HCL (Versed) Cousin to Valium with amnesia Needs a Narcotic for analgesia Propofol (Diprivan) New IV anesthetic Amnesiac Emulsion

Inhalation Cricoid Pressure

Tools of the Trade Blades and Scopes

Risks of Gas Anesthetics Most are explosive Nausea and vomiting Coughing Renal and liver toxicity

Neuromuscular blocking agents Succinylcholine chloride Pancuronium bromide (Pavulon) Relax the jaw and throat muscles immediately following induction so endotraceal tube can be place to maintain a patent airway and facilitate alveolar ventilation during surgery Used for complete relaxation of the abdominal muscles May cause circulatory compromise and respiratory muscle paralysis during the surgery

Malignant hyperthermia (MH) -inherited myopathy -hypermetabolic state -exposed to some anesthetic agents especially succinylcholine. -reduction in the reuptake of calcium necessary for termination of muscle contraction -muscle contraction is sustained -signs of hypermetabolism. -happens in the operating room -first few hours of recovery from anesthesia.

Clinical manifestations of MH Hypercarbia abnormally high concentration of carbon dioxide in the blood Tachycardia Tachypnea Temperature elevation (usually a late sign of MH) Hypertension Cardiac dysrhythmias Acidosis Hypoxemia Hyperkalemia (it should be considered first in case of cardiac arrest) Skeletal muscle rigidity (the most specific sign) Myoglobinuria

Regional Anesthesia Four common types Topical Infiltration Nerve Block Spinal Prevent the generation and conduction of nerve impulses Side effects can include Restlessness, Tremors and/or clonic convulsions CNS depression, respiratory depression and death Cardiovascular collapse if significant amount enter the systemic circulation

Topical Anesthetics Topical Application of EMLA Cream Advantages reduces anxiety provides localized pain control does not require a needlestick Disadvantages minimum of 1 hour to be effective peaks in 3-4 hours not recommended for neonates may cause blanching of the skin and vasoconstriction

Topical Anesthetics Transdermal - Numby Stuff Advantages provides local pain control does not require needle stick Disadvantages requires 7-10 minutes to be effective skin may appear blanched, red, irritated, blistered potential of skin burns

Infiltration

Nerve Block

Pudendal Block(Saddle Block) Lumbar Block

Spinal

Nursing Responsibilities anesthetized body part protection vital signs -Hypotension urinary retention Prevention of infection -indwelling catheter spinal headache: -recumbent position for at least 12 hours -adequate fluid replacement -Blood patch

Patient Identification Extremely important ID bracelet not to be removed Confirmed by all personnel from surgical floor to recovery room

Patient Positioning After administration of anesthesia Best possible access Best possible visualization Access must be provided to Surgical site Airway IVs Monitoring devices Compromise to body systems must be prevented

Positioning Supine Trendelenburg

Reverse Trendelenberg Fowlers Position

Sitting Position Lithotomy Position

Prone Kraske (jack knife) Position

Right Lateral Position Right Kidney Position

Lithotomy position with Trendelenberg

Final Patient Skin Prep

Abdominal Prep Left breast or Chest Prep

Perineum

Sterile Draping

Surgeon Preference Card

Scapel Blades

Retractors

Mechanical and Thermal Hemostasis Mechanical Clamps Ligature Clips Pledgets Sponges Bone wax Suction Thermal Electrosurgery Monopolar Bipolar Laser

Instrument Classification Cutting/dissecting Grasping/holding Clamping/occluding Retracting/viewing Probing Dilating Suturing Suctioning

Needle Point Cutting Tough tissue Skin Ophthalmology Tapered Delicate tissue Bowel Artery Blunt Kidney Liver

Suture Types Absorbable Nonabsorbable Monofilament Multifilament Suture ties Size Selected to correspond to type of tissue

What happens when someone undergoes surgery? Physiological insult that evokes stress response -sympathetic nervous system activation -increased adrenaline -heart beats faster -breathing/perspiration increase -eyes dilate -inhibition of GI peristalsis - peripheral perfusion shunted from skin to muscles. -ADH secreted; causing water retention -Cortisol released Increased Basal Metabolic rate Reduced immune response with diminished inflammation response Insulin resistance

Hypothermia abdominal or thoracic organs/tissues are exposed to room temperature for prolonged periods. Ventricular fibrillation, most frequent drop in heart muscle temperature below 28C. (82.4 F) Prolonged clotting time. Dehydration excessive loss of body water when abdominal or thoracic tissues are exposed to room air for prolonged periods. Compartmental fluid shift because of swelling at the operative site (Increased interstitial fluid)

Bear Hugger Warms up cold patients, not necessarily shivering patients

Microsurgery Nerve repair Anastomosis of a nerve Anastomoses of successively smaller blood vessels and nerves (typically 1 mm in diameter) Free tissue transfer Replantation

Laparoscopy Advantages over standard techniques: Less blood loss during surgery Shorter hospital stays Decreased recovery time Decreased reliance on narcotic pain medications Less fluid buildup

Traditional Laparoscopic

What is everyone looking at????

Cholecystectomy

On the horizon: Fetal Surgery

Transfering Patient from OR Table to Gurney Use a transfer board Anesthiologist handles the head

Immediate postoperative phase 1-4 Hours after surgery Post-anesthesia care unit Assessment every 15 minutes Body temperature stabilized and heat loss prevented Neurological Assessment Fluid and Electrolyte Balance Check bladder for distention

Immediate postoperative phase Monitor Cardiovascular system A,B,C Shock: increased pulse, decreased blood pressure, poor perfusion (capillary refill) Wound evaluated for hemorrhaging and drainage Pain medication given as needed Monitor for nausea and vomiting especially with decreased pharyngeal reflexes Transfer to nursing unit when awake and stable

Scrub nurse Performs surgical hand scrub Dons sterile gown and gloves aseptically Arranges sterile supplies and instruments Checks instruments for proper functioning Gowns and gloves surgeons as they enter operating room Assists with surgical draping of patient

Maintains count of sponges, needles, and instruments so none will be misplaced or lost Counts sponges, needles, and instruments with circulating nurse before wound closed Maintains neat and orderly sterile field Corrects breaks in aseptic technique Observes progress of surgical procedure Hands surgeon instruments, sponges, and necessary supplies during procedure Identifies and handles surgical specimens correctly

Circulating Nurse Sends for patient Visits with patient preoperatively: verifies operative permit, identifies patient, and answers questions Performs patient assessment Checks medical record Assists in transfer of patient Positions patient on operating table

Circulating Nurse Prepares equipment and supplies Arranges suppliessterile and non-sterile Counts sponges, needles, and instruments before surgery Assists scrub nurse in arranging tables for sterile field Maintains continuous astute observations during surgery to anticipate needs of patient, scrub nurse, surgeon, and anesthesiologist Provides supplies to scrub nurse as needed

Circulating Nurse Observes sterile field closely Cares for surgical specimens Documents operative record and nurses notes Counts sponges, needles, and instruments before closure of wound begins Transfers patient to the stretcher for transport to recovery area Must be careful to slowly change patients position to prevent hypotension Accompanies patient to the recovery room and provides a report