1510 Intra-Operative
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| 1-4 points of Surgical Asepsis | Contact with wound must be sterile; Fronts of gowns are considered sterile from chest to level of sterile field; Sleeves of gowns 2 inches above elbow to cuff; Only top of sterile drape is considered sterile, positioned front to back
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| 5-9 points of Surgical Asepsis | Sterile to sterile, unsterile to unsterile;Movement around sterile field must be restricted to at least one (1) foot away;If sterile barrier is breached, consider contaminated; Prepare sterile field as close as possible to procedure
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| Difference in medical and surgical asespsis? | Medical asepsis is clean technique whereas surgical asepsis is sterile technique
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| Types of General Anesthesia | Inhalation-Vapors are inhaledPatient is intubated, anesthesiologist administers with oxygenIntravenous-Barbiturates, benzodiazepines, hypnotics, analgesics, muscle relaxantsCan be used with inhalation anesthesia or alone
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| Stages of General Anesthesia | Stage 1- Beginning anesthesiaStage 2- ExcitementStage 3- Surgical anesthesiaStage 4- Medullary depression
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| Attributes of Stage 1 Anesthesia | Pt hears noise in animation-amplification. Try to reduce noise
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| Attributes of Stage 2 Anesthesia | pt may be restrained to prevent injury
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| Attributes of Stage 3 Anesthesia | pt should be unconscious and unresponsive
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| Attributes of Stage 4 Anesthesia | CNS is to far depressed. Can be fatal
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| Types of Regional Anesthesia | TopicalLocalEpiduralSpinalLocal Conduction Block (Nerve Block)
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| Moderate Sedation | airway intervention not required; self ventilation; CV function usually maintained; purposeful response to repeated or painful verbaal or tactile stimuli; RN
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| Monitored Anesthesia Care | Airway intervention may be required; self ventilation may be inadequate; CV function usually maintained; purposeful response after stimulation; CRNA
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| Versed (midazolam) | Benzodiazepine; sedative/hypnoticUsed to reduce anxiety and induce amnesia/sedation for procedure/testUsual dose IV: 1 mg initially, titrated to patient’s sedation required, total dosage > 4 mg rare; PO 5-10 mg
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| Versed AE | Can cause respiratory depression!Side Effects: drowsiness, dizziness, headaches, dry mouth, blurred vision
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| Demerol (meperidine hcl) | Opioid analgesicUsed as anesthesia adjunct or for sedationUsual dose IV: 25 mg given in increments
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| Demerol AE | Can cause respiratory depressionSide Effects: drowsiness, dizziness, headaches, dry mouth, blurred vision
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| Narcan (naloxone | Opioid antagonistUse: Reversal of CNS depression because of suspected opioid overdosageRoutes: Usually IVUsual dose IV: 0.4mg q2-3min, up to 2mg
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| Narcan AE | Side Effects: hypertension, hypotension, tachycardia, N&VMonitor vital signs frequently (every 5-15 minutes) for 3-4 hours after administration
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| Circulating Nurse Duties 1 | Universal Protocol (Time-Out) PRIORITY!Two patient identifiers;Question the patient to determine if he/she understands the procedure;Ensure that site is CLEARLY marked
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| Circulating Nurse Duties 2 | Signed Informed Consent should be in prominent area of chart – MUST be witnessed by pre-op nurse;Consent should clearly state what procedure is to be done, what site, and what side;Is there an Advance Directive/Living Will/DNR on the chart; Allergies
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| Circulating Nurse Duties 3 | Check IV, NG Tube, Foley CatheterPatient should be wearing cap and gown that allows easy access to surgical siteIf ordered, are TED hose or SCDs in place?Make sure any special equipment needed is available and functioning properly
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| Circulating Nurse Duties 4 | Check patient’s response to pre-op medsReduced anxietyDry mouthIf administering Moderate Sedation, must assess the patient continuouslyB/P, Pulse, Resp, anxiety level, pain level q5min or more as neededContinuous pulse oxEthical Concerns
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| Patient Safety Precautions | Proper Patient PositioningMonitor and maintain aseptic environmentMaintain catheters, tubes, drains, and specimensPerform sponge, sharps, and instrument counts
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| Post-op Nausea and Vomiting | Anticholinergics usually given PreOp to prevent aspiration:Atropine RobinulFirst action is to turn patient to side to prevent aspiration May also receive antiemetics:Promethazine (Phenergan)Hydroxyzine Pamoate (Vistaril)Ondansetron (Zofran)
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| Phenergan (promethazine hcl) | Antiemetic; sedative/hypnoticUse: Prevention or tx of N/V, pre-op sedation, adjunct to anesthesia and analgesiaRoutes: PR, PO, IM, *IVDoes not mix with some meds Usual dose: 12.5 – 50 mg
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| Phenergan (promethazine hcl)AE | Side effects: Dizziness, drowsiness, sedation, burning & pain at IV site
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| Vistaril (hydroxyzine pamoate) | Antiemetic; anti-anxiety; sedative/hypnoticUse: May be given pre-op as anti-anxiety, but often during surgery as anti-emeticRoutes: PO, usually IMAdminister ONLY deep IM into well-developed muscle with Z-track methodUsual dose: 25-100 mg
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| Vistaril (hydroxyzine pamoate)AE | Side effects: drowsiness, agitation, ataxia, dizziness, pain/abscess at IM site
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| Zofran (ondansetron) | AntiemeticUse: Prevention/tx of N/VRoutes: PO, IM, usually IVUse no more than 8 mg/day in hepatic impairmentUsual dose: 4mg
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| Zofran (ondansetron)AE | Side effects: dizziness, drowsinessBe sure to check IV compatibility
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| Symptoms of Anaphylaxis | Peripheral tinglingFullness in mouth and throatFlushing, warmth, anxietyBronchospasms, edema of airways or larynxDyspnea, cough, wheezingAbdominal cramping, vomiting, diarrhea, seizuresCardiac arrest, coma
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| Ineffective Airway Clearance | Individual experiences a threat to respiratory status related to inability to cough ineffectively
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| Ineffective Breathing Pattern | Individual experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern
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| Ineffective Tissue Perfusion (Peripheral) | Individual experiences a decrease in oxygenation at the capillary level
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| Deficient Fluid Volume | Individual experiences dehydration
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| Hypothermia | Individual has a sustained reduction of body temperature of < 98°F rectally due to external factors
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| Risk for Aspiration | Risk for entry of secretions, solids, or fluids into the tracheobronchial passages
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| Risk for Imbalanced Body Temperature | At risk for hyperthermia, hypothermia, or ineffective thermoregulation
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| Risk for Fluid Volume Imbalance | At risk for a decrease, increase, or rapid shift of fluids (intravascular, interstitial, and/or intracellular)
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| Risk for Perioperative Positioning Injury | At risk for harm as a result of positioning requirement during surgery, unable to protect self due to anesthesia
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| Risk for Infection | At risk for invasion by microorganism (virus, fungus, bacterium, protozoan, or other parasite)
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| Unintentional Hypothermia | Indicated by core body temperature of less than 98 degrees (36.6 degrees C)Often give warmed IV fluids (98.6F)Increase room temp temporarily to 78-80F Warming must be done gradually, not rapidly
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| Malignant Hyperthermia | Rare inherited muscle disorderWas a 80% mortality rate, now 10%Tachycardia earliest symptom Rise in temperature is a late sign and can reach above 104 degrees
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| Disseminated intravascular coagulation.DIC | Cause: thrombus formation in the microcirculationDepletion of select coagulation proteinsThese processes lead to hemorrhaging
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| Infection/Sepsis | May become septic during procedureCan occur when the surgery involves infected tissues – infection spreads rapidly within the blood stream
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| Signs of shock | Increased heart rateRapidly decreasing blood pressureDiaphoresisPatient’s temperature will be elevated, and will continue to rise
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| Hypoxia/Other Respiratory Complications | Brain damage from hypoxia occurs within minutesCapillary refill < 3 secs, nail beds pinkCheck peripheral pulses to check perfusion, esp. in vascular surgery
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| Causes of Anaphylaxis | MedicationsMost common cause of anaphylaxisLatexAdhesivesFibrin sealantsCyanoacrylate tissue adhesives
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