INTRAOPERATIVE PHASE

Intraoperative Phase - Transferred to OR-ends with the transfer to the recovery area. Transfer onto the operating table Phases of anesthesia Operative proceedure Transfer from operating table to stretcher Safe transport to post-operative area (PACU)

SURGICAL TEAM Surgeon Anesthesiologist Scrub Nurse Circulating Nurse OR techs

Surgical team Surgeon 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. Scrub nurse- 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 Circulating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative 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- 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, EVS personnel.

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

Elements of Aseptic Technique *Sterile gowns and gloves. *Sterile drapes used to create sterile field. *Sterilization of items used in sterile field.

Surgical asepsis The absence of pathogenic microorganisms. Ensure sterility Alert for breaks The practice of aseptic technique requires the development of sterile conscience, an individual’s personal honesty and integrity with regard to adherence to the principles of aseptic technique.

Preanesthetic Preparation Avoidance of foods and drink prevents passive regurgitation of gastric contents Clients should typically continue medications up to surgery Consent must be received

Sedation Reduction of stress, excitement, or irritability and some suppression of CNS Typically used to relieve anxiety and discomfort during a procedure Residual effects include amnesia and letheragy

Types of Anesthesia Regional Local Nerve block Epidural Spinal General

Spinal Anesthesia Injected into cerebrospinal fluid (approx L 3-5) subarachnoid space 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

Spinal Anesthesia (Subarachnoid Block) Anesthesia: tip of xiphoid to toes Risks: – Loss of vasomotor tone – “Spinal Headache” – Infection, Rising anesthesia above diaphragm Nursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE

General Anesthesia Inhalation-Mask, Endotracheal tube (ETT) or Laryngeal managed airway (LMA) Intravenous Combination

General Anesthesia: Inhalation Agents Inhalation most controllable method; lungs act as passageway for entrance & exit of agent Gas Agents : Nitrous Oxide – must be given with oxygen – require assisted to mechanical ventilation – frequently shiver – taken in & excreted via lungs – Examples: halothane, enthrane, florane…

Adjuncts to General Anesthesia Hypnotics (Versed, Valium) – also used for conscious sedation Opioid Analgesics (morphine, Demerol) – respiratory depression Neuromuscular Blocking Agents – Causes muscle paralysis – Examples: Pavulon, Succinycholine – What vital function is affected?

Potential General Anesthesia Complications Overdose (consider risk factors) Hypoventilation postoperatively Intubation related: sore throat, hoarseness, broken teeth, vocal cord trauma MALIGNANT HYPERTHERMIA – Genetic predisposition – Triggered by anesthetics such as Halothane

Potential Intraoperative Complications Nausea and vomiting Anaphylaxis Respiratory complications Inadequate ventilation, airway occlusion, intubation of the esophagus, and hypoxia Hypothermia Malignant hyperthermia Disseminated Intravascular Coagulation What are measures to prevent or treat these complications?

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

Intraoperative Nursing Care Risk of infection related to invasive procedure and exposure to pathogens. Risk for injury related to positioning during surgery. Risk of injury related to foreign objects inadvertently left in the wound. Risk for injury related to chemical, physical, and electrical hazards. Risk for impaired tissue integrity. Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status. Nurses are responsible for managing six areas of risk:

Nursing Process Intraop Phase Intervention – Safety – Advocacy – Verification – Counting-instruments, sponges, needles

Altered Skin Integrity How many sutures? Staples or sutures or glue???

POSTOPERATIVE PHASE

Postoperative Postoperative - Begins with transfer to PACU and ends with the discharge of the patients from the surgical facility or the hospital. Nursing Interventions Nursing Interventions Communicating pertinent information about surgery to the PACU staff. Postoperative evaluation in clinic or home.

Nursing assessment in the Recovery Room Vital signs- presence of artificial airway, o2 sat,BP,pulse, temperature. Ability to follow command, pupillary response Urinary output Skin integrity Pain Condition of surgical wound Presence of IV lines Position of patient

Immediate Post-anesthesia Care Airway Breathing Circulation How often should vital signs be assessed?

Postop SKIN Assessment “Altered Skin Integrity” Day 3 or so to Day 14 (or 21 or more) – Proliferation: fibrin strands form scaffold Collagen with blood = granulation tissue Protect from damage or stress – No lifting, heavy exercise, driving etc. At risk for dehiscence or evisceration Day 15 (or weeks, months, years) – Scar is organized, less red, stronger – Max strength = 70 – 80%

Postoperative RESPIRATORY Assessment Impaired gas exchange or impaired airway clearance Risks: pneumonia, atelectasis Assessment: – Open airway – Pulse oximetry (what is normal?) – Check opioid use (why?) – Monitor quality & quantity of respirations

Postoperative RESPIRATORY Assessment Interventions: – Turn (also relates to cardiovascular risk – any ideas?) – Deep breathe & cough – Incentive spirometry – In-bed exercises (see text) – AMBULATION!!

Postop SKIN Assessment “Altered Skin Integrity” Wound healing – How is the face healing time-line different from the foot? OR to Day 2 (may 3-5) – Inflammation vs. infection redness, pain, swelling, warmth skin held together by blood clots & tiny new blood vessels – Avoid pressure/ be sure to splint

Postop CARDIOVASCULAR Assessment: Potential for hypoxemia Think (hypovolemic) shock (hemorrhage) – Assessment: Prevention of venous stasis – Who is at risk? – What should be done?

Avoiding Venous Stasis Avoidance of positions leading to venous stasis In Bed Exercises Antiembolism stockings Sequential Compression Device When all is said & done, AMBULATION is the best!

Postop NEUROLOGIC Assessment Assess cerebral function – Think elderly Assess motor/sensory function

Postop F & E Assessment Fluid Status – Intake – Output Why would a postop client need an IV??

Postop URINARY Assessment Anuria (define) Urinary Retention – Or Urinary retention with overflow Differentiate Intervention: – Fluids – AMBULATION – Careful monitoring

Postop GI Assessment Nausea & vomiting Assessment of peristalsis/paralytic ileus Interventions: – N/G tube, GI rest (NPO), AMBULATION Postop Diets – Why are clear liquids usually the first diet? – What does “advance as tolerated” mean? – What are nursing responsibilities??

Postoperative Diets 1. Clear Liquid 2. Full Liquid 3. Soft 4. Regular Postop Diets – Why are clear liquids usually the first diet? – What does “advance as tolerated” mean? – What are nursing responsibilities??

Postop SKIN Assessment “Altered Skin Integrity” R edness E dema E cchymosis D rainage A pproximation Is a scar as strong as the original skin?

The Ultimate in “Altered Skin Integrity” Risk factors: -Dehiscence -Evisceration Prevention: -Wound Splinting -Abdominal binder -Diet

Nursing Diagnosis Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain Ineffective breathing pattern- anesthetic and drug effects, incisional pain Acute pain Urinary retention Risk for infection

Postoperative Goals Re-establishment of physiologic equilibrium Alleviation of pain Prevention of complications

Postoperative Management Maintain a patent airway Stabilize vital signs Ensure patient safety Provide pain Recognize & manage complications

When caring for post-surgical patient, think of the “4 W’s” Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis

Complications Respiratory- atelectasis, pulm. Embolus Cardiovascular- venous thrombosis Gastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer. GU- urinary retention Hemorrhage-slipping of a ligature(suture) Wound infection- Wound dehiscence and evisceration-

Postoperative Pain Control What is the definition of Pain? As nurses, what do we need to remember about the pain experience? What is the key reason to control postoperative pain?