The Intraoperative Patient

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The Intraoperative Patient
By Lisa M. Dunn RN, MSN/ED, CCRN
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Members of the Surgical Team

• Surgeon
• Surgical assistant
• Anesthesiologist
• Certified registered nurse anesthetist
• Holding area nurse
• Circulating nurse
• Scrub nurse
• Surgical technician/ Operating room technician

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Environment of the Operating Room

• Preparation of the surgical suite and team safety
• Layout
• Health and hygiene of the surgical team
• Surgical attire
• Surgical scrub

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Surgical Scrub, Gowning, and Gloving
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Anesthesia

• Induced state of partial or total loss of
  sensation, occurring with or without loss of
  consciousness.
• Used to block nerve impulse transmissions,
  suppress reflexes, promote muscle relaxation,
  and, in some instances, achieve a controlled
  level of unconsciousness.

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General Anesthesia

• Reversible loss of consciousness is induced by
  inhibiting neuronal impulses in several areas of
  the CNS.
• State can be achieved by a single agent or a
  combination of agents.
• CNS is depressed, resulting in analgesia,
  amnesia, and unconsciousness, with the loss of
  muscle tone and reflexes.

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Stages of General Anesthesia
Stage 1 analgesia Stage 2 excitement Stage 3
operative Stage 4 danger
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Administration of General
Anesthesia

• Inhalation intake and excretion of anesthetic
  gas or vapor to the lungs through a mask
• Intravenous injection barbiturates, ketamine,
  and propofol through the blood stream
• Adjuncts to general anesthesia agents hypnotics,
  opioid analgesics, neuromuscular blocking agents

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Balanced Anesthesia

• Combination of intravenous drugs and inhalation
  agents used to obtain specific effects
• Combination used to provide hypnosis, amnesia,
  analgesia, muscle relaxation, and reduced
  reflexes with minimal disturbance of physiologic
  function.

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Balance Anesthesia Continued

• Example
• -thiopental for induction
• -nitrous oxide for amnesia
• -morphine for analgesia
• -pancuronium for muscle relaxation

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Complications from General Anesthesia

• Malignant hyperthermia possible treatment with
  dantrolene
• Overdose
• Unrecognized hypoventilation
• Complications of specific anesthetic agents
• Complications of intubation

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Question

• In treating the client with malignant
  hyperthermia, the most important intervention is
• Initiation of cooling measures
• Administration of skeletal muscle relaxant
• Reversal of anesthesia
• Increasing rate of intravenous fluids

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Local or Regional Anesthesia

• Sensory nerve impulse transmission from a
  specific body area of region is briefly disrupted
• Motor function may be affected
• Patient remains conscious and able to follow
  instructions
• Gag and cough reflexes remain intact
• Sedatives, opioid analgesics, or hypnotics are
  often used as supplements to reduce anxiety.

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Local Anesthesia

• Topical anesthesia
• Local infiltration
• Regional anesthesia
• -field block
• -nerve block
• -spinal anesthesia
• -epidural anesthesia

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Question

• In reviewing preoperative teaching for a client
  scheduled to have regional anesthesia, which
  statement by the client indicates that additional
  teaching is needed?
• My legs may be numb for a while.
• I hope I dont get too nervous being awake.
• It will be difficult to move my legs immediately
  after surgery.
• I am relieved that I will be asleep during this
  procedure.

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Complications of Local or Regional Anesthesia

• Anaphylaxis
• Incorrect delivery technique
• Systemic absorption
• Overdosage

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Complications of Local or Regional Anesthesia
continued.

• Assess for CNS stimulation
• Assess for CNS and cardiac depression
• Assess for restlessness, excitement
• Assess for incoherent speech
• Assess for headache, blurred vision
• Assess for nausea/vomiting, metallic taste
• Assess for tremors and/or seizures
• Assess vital signs against base line vital signs

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Surgical Fires
Goal 11 Reduce the risk of surgical fires
NPSG.11.01.01 The organization educates staff,
including licensed independent practitioners who
are involved with surgical procedures and
anesthesia providers, on how to control heat
sources, how to manage fuels while maintaining
enough time for patient preparation, and
establish guidelines to minimize oxygen
concentration under drapes.
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2005 Thyroid Surgery. Patient had 12
reconstruction surgeries
Growing use of electrosurgical devices and paper
hospital drapes have contributed to fires in the
operating room.
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affecting between 550 and 650 patients a year,
including 20 to 30 who suffer serious,
disfiguring burns. Every year, one or two people
die this way (MSNBC, 2006).
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Question

• An operating room nurse is positioning a client
  on the operating room table to prevent the
  clients extremities from dangling over the sides
  of the table. A nursing student who is observing
  for the day asks the nurse why this is so
  important. The nurse responds that this is done
  primarily to prevent
• An increase in pulse rate
• A drop in blood pressure
• Nerve and muscle damage
• Muscle fatigue in the extremities

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Question

• A nurse is preparing a preoperative client for
  transfer to the operating room. The nurse should
  take which action in the care of this client at
  this time?
• Ensure that the client has voided
• Administer all the daily medications
• Practice postoperative breathing exercises
• Verify that the client has not eaten for the last
  24 hours

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Treatment of Complications

• Establish an open airway
• Give oxygen
• Notify the surgeon
• Fast-acting barbiturate is usual treatment
• If toxic reaction is untreated, unconsciousness,
  hypotension, apnea, cardiac arrest, and death may
  result.

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Conscious Sedation

• IV delivery of sedative, hypnotic, and opioid
  drugs reduce the level of consciousness but
  allows the patient to maintain a patent airway
  and to respond to verbal commands.
• Diazepam, midazolam, meperidine, fentanyl,
  alfentanil, and morphine sulfate are the most
  commonly used drugs.

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Conscious Sedation Continued
Nursing Assessment Includes -Airway -Oxygen
saturation -Level of consciousness -Electrocardi
ographic status -vital signs monitor every 15 to
30 minutes
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Collaborative Management

• Assessment
• Medical record review
• Allergies and previous reactions to anesthesia or
  transfusions
• Autologous blood transfusion
• Laboratory and diagnostic test results
• Medical history and physical examination findings

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Question

• A nurse is conducting preoperative teaching with
  a client about the use of an incentive
  spirometer. The nurse should include which piece
  of information in discussions with the client?
• Inhale as rapidly as possible.
• Keep a loose seal between the lips and the
  mouthpiece.
• After maximum inspiration, hold your breath for
  15 seconds and exhale.
• The best results are achieved when sitting up or
  with the head of the bed elevated 45 to 90
  degrees.

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Risk for Perioperative Positioning Injury

• Interventions include
• Proper body position
• Risk for pressure ulcer formation
• Prevention of obstruction of circulation,
  respiration, and nerve conduction

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Impaired Skin Integrity
Interventions include -plastic adhesive
drape -skin closures include sutures (absorbable
and nonabsorbable), staples, and dermabond,
retention sutures -insertion of
drains -applications of dressings -transfer of
a patient from the operating room table to the
stretcher or bed
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Special Drains

• Remove pus
• Remove blood
• Remove other body fluids from wound
• Does not result in faster wound healing or
  prevent infection.

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Penrose Drain
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Jackson Pratt or JP
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Hemovac
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Dressings
Dry or moist Gauze Hydrocolloid Protects the
wound from surface contamination Hydrogel Maintain
s a moist surface to support healing Wound
V.A.C. Uses negative pressure to support healing
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Dressings continued.
Changing Know type of dressing, placement of
drains, and equipment needed. Securing Tape,
ties, or binders Comfort measures Carefully
remove tape. Gently cleanse the wound. Administer
analgesics before dressing change.
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Montgomery Straps
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Ace wraps

• To reduce the swelling of an injured area of the
  body
• To hold wound bandages in place
• To wrap around a arm or leg splint during healing
• To improve blood flow to a limb like an arm or
  leg
• To hold cold or hot packs in place on a body part

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Ice pack

• A general rule of thumb is to ice an injury over
  a period of 24 to 72 hours.
• Apply cold packs for periods of up to 20 minutes
  every two to four hours.
• When your skin starts to feel numb, it's time to
  give your body a break from a cold pack.

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Question

• Which of the nursing interventions would the
  nurse implement for the older client to minimize
  skin breakdown related to surgical positioning?
• Padding bony prominences
• Taping joints in anatomic position
• Monitoring for excessive blood loss
• Applying elastic stockings to lower extremities

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Potential for Hypoventilation

• Continuous monitoring of
• -breathing
• -circulation
• -cardiac rhythms
• -blood pressure and heart rate
• Continuous presence of an anesthesia provider

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Question
A postoperative client asks a nurse why it is so
important to deep-breathe and cough after
surgery. In formulating a response, the nurse
incorporates the understanding that retained
pulmonary secretions in a postoperative client
can lead to A. pneumonia B. fluid imbalance C.
pulmonary edema D. Carbon dioxide retention
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Question

• A client with a perforated gastric ulcer is
  scheduled for surgery. The client cannot sign
  the operative consent form because of sedation
  from opioid analgesics that have been
  administered. The nurse should take which
  appropriate action in the care of this client?
• Obtain a court order for the surgery
• Send the client to surgery without the consent
  form being signed.
• Have the hospital chaplain sign the informed
  consent immediately.
• Obtain a telephone consent from a family member,
  following hospital policy.