The Intraoperative Patient

By Lisa M. Dunn RN, MSN/ED, CCRN

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

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

Surgical Scrub, Gowning, and Gloving

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.

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.

Stages of General Anesthesia

Stage 1: analgesia

Stage 2: excitement

Stage 3: operative

Stage 4: danger

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

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.

Balance Anesthesia Continued…

Example:

-thiopental for induction

-nitrous oxide for amnesia

-morphine for analgesia

-pancuronium for muscle relaxation

Complications from General Anesthesia

Malignant hyperthermia: possible treatment with dantrolene

Overdose

Unrecognized hypoventilation

Complications of specific anesthetic agents

Complications of intubation

Question

In treating the client with malignant hyperthermia, the most important intervention is:

A. Initiation of cooling measures

B. Administration of skeletal muscle relaxant

C. Reversal of anesthesia

D. Increasing rate of intravenous fluids

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.

Local Anesthesia

Topical anesthesia

Local infiltration

Regional anesthesia

-field block

-nerve block

-spinal anesthesia

-epidural anesthesia

Question

In reviewing preoperative teaching for a client scheduled to have regional anesthesia, which statement by the client indicates that additional teaching is needed?

A. “My legs may be numb for a while.”

B. “I hope I don’t get too nervous being awake.”

C. “It will be difficult to move my legs immediately after surgery.”

D. “I am relieved that I will be asleep during this procedure.”

Complications of Local or Regional Anesthesia

Anaphylaxis

Incorrect delivery technique

Systemic absorption

Overdosage

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

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.

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.

“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).

Question

An operating room nurse is positioning a client on the operating room table to prevent the client’s 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:

A. An increase in pulse rate

B. A drop in blood pressure

C. Nerve and muscle damage

D. Muscle fatigue in the extremities

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?

A. Ensure that the client has voided

B. Administer all the daily medications

C. Practice postoperative breathing exercises

D. Verify that the client has not eaten for the last 24 hours

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.

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.

Conscious Sedation Continued…

Nursing Assessment Includes:

-Airway

-Oxygen saturation

-Level of consciousness

-Electrocardiographic status

-vital signs monitor every 15 to 30 minutes

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

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?

A. Inhale as rapidly as possible.

B. Keep a loose seal between the lips and the mouthpiece.

C. After maximum inspiration, hold your breath for 15 seconds and exhale.

D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Risk for Perioperative Positioning Injury

Interventions include:

Proper body position

Risk for pressure ulcer formation

Prevention of obstruction of circulation, respiration, and nerve conduction

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

Special Drains

•Remove pus•Remove blood•Remove other body fluids from wound

•Does not result in faster wound healing or prevent infection.

Penrose Drain

Jackson Pratt or JP

Hemovac

Dressings

Dry or moistGauze

HydrocolloidProtects the wound from surface contamination

HydrogelMaintains a moist surface to support healing

Wound V.A.C.Uses negative pressure to support healing

Dressings continued.

Changing Know type of dressing, placement of drains, and equipment needed.

SecuringTape, ties, or binders

Comfort measuresCarefully remove tape.Gently cleanse the wound.Administer analgesics before dressing change.

Montgomery Straps

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

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.

Question

Which of the nursing interventions would the nurse implement for the older client to minimize skin breakdown related to surgical positioning?

A. Padding bony prominences

B. Taping joints in anatomic position

C. Monitoring for excessive blood loss

D. Applying elastic stockings to lower extremities

Potential for Hypoventilation

Continuous monitoring of:

-breathing

-circulation

-cardiac rhythms

-blood pressure and heart rate

Continuous presence of an anesthesia provider

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

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?

A. Obtain a court order for the surgery

B. Send the client to surgery without the consent form being signed.

C. Have the hospital chaplain sign the informed consent immediately.

D. Obtain a telephone consent from a family member, following hospital policy.