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Intraoperative care

Intraoperative chapter review

What is the intraoperative period? This begins when the patient enters the surgical suite and ends at the time of transfer to the postanesthesia reconvery are, same-day unit, or ICU
What are the main concerns during the intraop period? Safety and advocacy
What are some of the “at risks” in the OR? Risk for infection, impaired skin integrity, increased anxiety, altered body temp, and injury related to positioning and other hazards
Why is nursing care during the intra op period critical? b/c the patients physical needs, spiritual needs, comfort, safety, dignity, and psychological status depends on the periop nurse
Surgeon Is a physician who assumes responsibility for the surgical procedure and any surgical judgement about the patient
Surgical assistant Might be another surgeon or PA, CRN, CRNFA, or surgical tech, they work under the direction of the surgeon and within the legal scope of practice for each state, the assistant may hold refractors, suction the wound, cut tissue, suture, and dress wounds
Anesthesiologist This is a physician who specializes in giving anesthesic agents
CRNA This is a RN with additional education and credentials who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist
What areas does the anesthesia provider need to be monitored during surgery? Level of anesthesia, cardiopulm functions, vital signs, and I&O
OR nurse This person used clinical decision-making skills, deveolpe a plan of nursing care, and coordinates care delivery to patient and their families
Holding area nurse They coordinate and manages the care while the patient is in this area. Greeting the pt, reviewing records, and preop checklist, verify consent signed, and document risk assessment
Circulating nurse coordinate, oversee, and are involved in the pt care in the OR, coordinate activities for the OR- all supplies, blood, diagnostic supports are available and inspected. Helps maintain count of scrubs, instruments, sharps, amt of irrigated fluids and drugs
Throughout surgery, the circ nurse has what responsibilities? Monitor traffic, assesses the amt of urine/blood loss, reports findings, all sterile fields are maintained by staff, anticipates needs of pt and team, communicated pt status with family, document care, events, interventions and findings
Scrub nurse/operating rooms tech, surgical tech, certifies surg tech (CST) They set up sterile field, drape the pt, and hand sterile supplies/equipment/instruments to surgeon. Must have knowledge of procedures, to pick correct tools. Helps maintain count of scrubs, instruments, sharps, amt of irrigated fluids and drugs
Specialty Nurse Particular type of surg (ortho, cardiac, ophthalmologic). They are responsible for care specific to patients needing that type of surg. Maintains, recommends equip, instruments, and supplies.
Laser specialty nurse or laser nurse coordinator Specially trained in the use, care and maintenance of the laser
What does laser mean? Light Amplification by the Stimulated Emission of Radiation- it gives off a high powered beam of light that cuts tissue
Who keeps count of all that is used in surgery from before the surgery to immediately before complete skin closure? Scrub and circulating nurse
What are the 3 zones of the OR? Unrestricted, semi-restricted and restricted
Define- minimally invasive surgery (MIS) This involves making one or more small incisions in the area of the surgery and placing an endoscope through the opening
What types of surgeries are preferred for MIS? Cholecystectomy, cardiac surgery, splenectomy and spinal surg
Define- endoscope This is a tube that allows viewing and manipulating on internal body areas. Some with magnification views. These are rigid, semirigid, or flexible
What are the different endoscopes and the uses? laparoscopes- abd surg, arthroscopes- joint surg, and ureteroscopes- UT surg
What are endoscopes are used for? organ removal, reconstructions, blood vessel grafting, cutting, suturing, stapling, cautery, laser surg and injecting gases
What important feature does endoscopes provide in abd, pelvic, and surg of other body cavity areas? insufflation
Define- insufflations injecting gas or air into the cavity before the surgeru to separate organs and improve visualization
Define- robotic technology this is endoscope technology. The surgeon inderts the instrument and positions the articulatinf arms and then breaks scrub and performs surg while sitting at the console. A 3D view is on screen of anatomy.
A periop nused specialist this is someone who provides education for patients and family and training for members of the surg team
What is the disadv of MIS and robiotic technology? cost of special equip, or OR setting
Define- nosocomial infections a hospital acquired source of pathogens
List what does the surgical scrub consists of? mask on first, a surgical scrub (plain or antimicrobial soap-elbow to hands 3-5min), rinse, drying with sterile towelor alcohol, gowning, gloving
Define- anesthesia “negative sensation,” is an induced state of partial or total loss of sensation, occurring with or without LOC
What is the purpose of anesthesia? to block nerve impulse transmission, suppress reflexes, promote muscle relazation, and in some cases, achieve a controlled LOunC
What are some factors in the selection and dose of anesthesia? health problems, type/duration of procedure, area of the body, safety issues, if emergency, options for pain after, length of last ingestion, fluids, drugs, pts positioning, if pt is to be alert for instructions, and previous responses, rxns
What are the 6 rankings for the physical status of a patient according to the ASA? Why is it used? a totally healthy patient is P1 ranking, to a patient who is brain dead- P6 ranking. It is used to estimate potential risks during surgery and pt outcomes
Define- general anesthesia a reversible LOC induced by inhibiting neuronal impulses in several areas of the CNS. Depressing the CNS.
How is general anesthesia achieved? with a single agent or combo of agents. Anesthesia depressed the CNS, resultsing in analgesia, amnesia and unconsciousness, with loss of muscle tone and reflexes. Pt is unaware
When is general anesthesia most given? surg of the head, neck, upper torso, and abd. And when patient cannot cooperate
Define- analgesia pain relief or pain suppression
Define- amnesia memory loss of the surgery
Define- emergence speed of recovery from anesthesia
What does emergence depend on? it deoends on the type of anesthetic agent,length of time the patient is anesthetized, and whether a reversal agent is used
What common effect during emergence/recovery does the patient incounter? retching, vomiting, and restlessness. In recovery shivering, rigidity and light cyanosis- due to the temporary changes in the body;s temp control
What are the 4 stages of induction of general anesthetics? Stage1-analgesia and sedation, relaxation; stage2- excitement, delirium; stage3-operative anesthesia, surgical anesthesia; stage4 danger
What happens in stage 1 of general anesthesia? Begins with induction and ends with loss of consciousness, Pt feels drowsy and dizzy, reduced sensation to pain, and is amnesic. Hearing is exaggerated.
What happens in stage 2 of general anesthesia? Begins with LOC and ends with relaxation, regular breathing, and loss of the eyelid reflex. Irregular breathing, increased muscle tone, and involuntary movement of the extremities, is susceptible to external stimuli. Laryngospasm or vomiting.
What happens in stage 3 of general anesthesia? Begins with muscle relaxation and ends with loss of reflexes and depression of vital functions, jaw is relaxed, and breathing is quiet/regular, cannot hear, sensations are lost.
What happens in stage 4 of general anesthesia? Begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death. Respiratory muscles are paralyzed; apnea occurs, pupils are fixed/dilated.
What are the ADV of General inhalants anesthetics? ADV: Most controllable method, Induction and reversal accomplished with pulmonary ventilation,Few side effects
What are the DISADV of General inhalants anesthetics? DIS: Must be combination with other agents for painful/prolonged procedures, limited muscle relaxant effects, Postoperative nausea and shivering common, Explosive
What are the ADV of General Intravenous anesthetics? ADV: Rapid and pleasant induction, Low incidence of postoperative nausea and vomiting, Requires little equipment
What are the DISADV of General Intravenous anesthetics? DIS: Must be metabolized and excreted from the body for complete reversal, Contraindicated in presence of hepatic or renal disease Increased cardiac and respiratory depression, Retained by fat cells
What are the ADV of General Balanced anesthetics? ADV: Minimal disturbance to physiologic function, Minimal side effects, Can be used with older and high-risk patients
What are the DISADV of General Balanced anesthetics? DIS: Drug interactions can occur, Pharmacologic effects on the body may be unpredictable
What are the ADV of Regional or Local anesthetics? ADV: Gag and cough reflexes stay intact, Allows participation and cooperation by the patient, Less disruption of physical and emotional body functions, Decreased chance of sensitivity to the agent, Decreased intraoperative stress
What are the DISADV of Regional or Local anesthetics? DIS: Difficult to admin to an uncoop/upset pt, No way to control agent after admin, Absorbs rapidly into blood and causes cardiac depression or OD, Increased Nerv sys stimulation (OD), Not good for extensive surg b/c of the amt need to maintain anesthesia
What are the ADV/DISADV of Cryothemia anesthetics? ADV: Reflexes remain intact, Decreases chance of adverse reactions, Decreased intraoperative stress; DIS: No way to control depth of anesthesia, Not used in long or extensive procedures, May not be appropriate for an anxious patient
What are the ADV/DISADV of hypnosis/hypnoanesthesia? ADV: Reflexes remain intact; DIS: Requires patient cooperation, Requires special training
Define- malignant hyperthermia (MI) this is an acute, life-threatening complication to certain drugs used for general anesthesia. This can occur immediately after onset, or several hrs into surgery.
What are the reactions involved in malignant hyperthermia? the rxn brgins with skeletal muscle exposure to the specific agents, causing increased Ca levels in the muscle clls and increased muscle metaboloism
What are the manifestations of malignant hyperthermia tachycardia, dysrhythmias, muscle rigidity, hypotension, tachpnea, skin motting, cyanosis and myoglobinuria. Late sign is febrile of around 111 F
Define-myoglobinuria? this is the presence of protein in the urine
What drug is used for malignant hyperthermia? dantrolene Na, a muscle relaxant
What is the mechanism and the effects of unrecognized hypoventilation? failure to exchange gases adequately can lead to cardiac arrest, permanent brain damage, and death
What are the reasons for intubation complications? anatomic variance, dz processes, improper neck extension
What are the intubation complications? broken or injured teeth and caps, swollen lips, vocal cord trauma, tracheal edema and irritation, and sore throat
Define- local this is anesthesia that is deliveryed topically to the skin or mucous membrance of the area, and by local infiltration
Define- regional anesthesia? this is a type of local anesthesia that blocks multiple peripheral nerves in a specific body region
When is regional anesthesia preferred? It is used when gereral anesthesia cannot due to medical problems, allergic rxns, patients preference-when offered, if the patient has eaten, emergency surgery, and to decrease risk for aspirations
How does general anesthesia work? it briefly disrupt sensory nerve impulse transmission from a specific body area or region
How is local and regional anesthesia achieved? supplemented sedatives, opioids, analgesics, or hypnotics to reduce anxiety and increase comfort
What are the types of regional anesthesia? digital blocks, nerve block, spinal or epithelial.
Define- digital block, when is it used? this is a series of injections around the operative field. Used for chest procedures, hernia repair, dental surg, and some plastic surg
Define- nerve block, when is it used? injection of the local anesthetic agent into or around one nerve or group of nerves in the involoved area. used for limb surgery or to relieve chronic pain
Define- spinal anesthesia, when is it used? Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space. used for lower abdominal, pelvic, hip, and knee surgery
Define- epidural anesthesia, when is it used? Injection of an agent into the epidural space. Used for anorectal, vaginal, perineal, hip, and lower extremity surgeries
Medications for Inhalation anesthetics Desflurane (Suprane), Enflurane (Ethrane), Halothane (Fluothane), Isoflurane (Forane), Sevoflurane (Ultane), Nitrous oxide (N2O)
Medications for IV anesthetics Etomidate (Amidate),Ketamine (Ketalar), Midazolam (Versed), Propofol (Diprivan), Methohexital sodium (Brevital), Thiopental sodium (Pentothal)
Medications for neuromuscular blocker anesthetics Succinylcholine (SUX, Anectine), Atracurium (Tracrium), Cisatracurium (Nimbex), Mivacurium (Mivacron), Vecuronium (Norcuron), Pancuronium (Pavulon)
Medications for opioid anesthetics Alfentanil (Alfenta), Fentanyl (Sublimaze), Remifentanil (Ultiva), Sufentanil (Sufenta)
What are the anesthetic medications that do NOT have rapid induction and recovery? All but Midazolam (Versed), Methohexital sodium (Brevital), Pancuronium (Pavulon), Fentanyl (Sublimaze), Remifentanil (Ultiva)
Which IV anesthetic if useful for short procedures? Etomidate (Amidate)
Which IV anesthetic acts directly on the CNS? Methohexital sodium (Brevital)
Which anesthetic can induce malignant hyperthermia? Desflurane (Suprane), Enflurane (Ethrane), Halothane (Fluothane), Isoflurane
Define- conscious sedation this is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the LOC but allow the patient to maintain a patent airway and to respond to verbal commands
What procedures use conscious sedation? endoscopy, cardiac catheterization, closed fx reduction, cardioversion, and other special but short procedure
What medications are used in conscious sedation? Etomidate (Amidate), diazepam (Valium, Vivol, Novo-Dipam), midazolam (Versed), meperidine (Demerol), fentanyl (Sublimaze), alfentanil (Alfenta), and morphine sulfate
What are the nurse’s roles in the delivery of regional anesthesia? Assisting provider, Observing for breaks in sterile technique, Providing emotional support for the pt, Staying with the pt, Offering information and reassurance, Positioning the pt comfortably and safely
Who may administer conscious sedatives? a credentialed nurse( advanced IV drug delivery training, airway management, advanced cardiac life support) under the supervision of a physician and within the state-defined scope of nursing
What should the nurse monitor when conscious sedatives are given? airway, LOC, O2 saturation, ECG, vitals q15-30min
What is the actions for advanced directives, DNR orders during surgery? These directives are to be honored in the surgical environment regardless of the situation. Care of patients with DNR orders states that suspending a DNR order during surgery violates a patient's right to self-determination
Define- absorbable sutures these are digested over time by body enzymes
Define- Nonabsorbable sutures these become encapsulated in the tissue during the healing process and remain in the tissue unless they are removed. Body enzymes do not affect nonabsorbable sutures
When are retention (stay)sutures used? these may be used in addition to standard sutures for patients at high risk for impaired wound healing (those having major abdominal surgery, obese patients, patients with diabetes, and those taking steroids)
What are some of the outcomes for the intraoperative patient patient? Is safely anesthetized without complications?
Created by: kmichalle
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