Med Surg- Ch.19

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Med Surg- Ch.19
2012-01-17 20:48:16

Intraoperative Care
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  1. Surgical Suite
    • controlled environment designed to minimize the spread of infectious organisms
    • divided into 3 areas - unrestricted, semirestricted, and restricted
  2. Unrestricted area
    • where ppl in street clothes interact with those in scrub clothing
    • points of entry for the pts (holding area), staff(locker rooms), and information(nursing station, control desk)
  3. Semirestricted area
    • surrounding support areas and corridors
    • only authorized staff are allowed
    • must wear surgical attire and cover all head and facial hair
  4. Restricted areas
    • ORs
    • scrub sink areas
    • clean core
    • masks are required to supplement surgical attire
  5. Operating Room
    • unique setting removed from other hospital clinical units
    • controlled geographically, environmentally, and bacteriologically
    • restricted in/out-flow of staff
    • filters/controlled airflow
    • positive air pressure
    • ultraviolet lighting
    • omission of dust collecting table tops/shelves
    • materials resistant to corroding of cleanning agents
  6. Circulating nurse
    • not scrubbed, gowned, and gloved
    • remain in unsterile field
    • records all nursing care
    • checks mechanical/electrical equipment and environmental factors
    • admits pt to OR suite
    • coordinates all activities in room with team mbrs, other staff and dept.'s
    • records, labels, and sends blood and tissue specimens to proper locations
    • counts sponges, needles, instruments, etc.
    • accompanies pt to PACU & gives nursing report
    • applies monitoring devices (BP cuff, ECG, urinary catheters, etc)
  7. Scrub nurse
    • follow designated scrub procedure
    • are gowned, gloved in sterile attire
    • remain in sterile field
    • Scrubs, gowns, and gloves self and others
    • prepares instrument table/equipment
    • passes instruments to surgeon/ assistants
    • counts sponges, needles, instruments, etc.
    • monitors irrigation solutions used
    • reports amount of medications used by ACP
  8. Surgeon
    • physician who performs the surgical procedure
    • chooses surgical procedure
    • mgmt of pre-op testing
    • discusses risks/alternatives w/pt
    • pt safety and mgmt in OR
    • Post-op mgmt of pt
    • Surgeon assistant- holds retractors to expose areas, assists w/ homeostasis and suturing
  9. Registered Nurse First Assistant (RNFA)
    • collaborates with surgeon to produce optimal outcome- handles tissues, using instruments, providing exposure to the surgical site, assists with homeostasis, and suturing
    • formal education required
  10. Anesthesia Care Provider (ACP)
    • administers anesthesia - (anethesiologist or nurse anesthetist
    • assigns anesthesia classification
    • protects life functions and vital organs
    • manages pain, CPR, problems with pulmonary care, critically ill pts in special care units
    • after surgery-maintain pt in comfortable state during recovery and provision of care in PACU
  11. Specific questions regarding to the details of the surgical procedure and anethesia may be referred to:
    the surgeon or ACP
  12. Preoperative nursing assessments that decrease surgical risk factors:
    • Allergies- prevent catastrophic reactions
    • skeletal/muscle impairments- prevent injury during positioning
    • presence of piercings- remove to prevent site burns with electrosurgery
    • sensory deficits- adapting communication techniques
    • altered LOC- increased safety/protection measures
    • NPO status- aspiration
    • sources of pain- prevent unnecessary discomfort
    • medications, herbs, supplements- alterations with anesthesia
  13. Surgical attire
    • pants and shirt
    • mask
    • protective eyewear
    • caps/hoods
    • worn by all entering the OR
  14. Universal Protocol
    • preventing wrong site, wrong procedure, and wrong surgery
    • safety checklists
    • surgical time-out-surgicall team stops what they are doing just before surgery starts to verify identification of pt, surgical procedure, and surgical site
  15. Most common position used
  16. Antimicrobial agents need to:
    • reduce microorganisms on intact skin
    • nonirritating antimicrobial agent
    • broad spectrum
    • fast acting
    • persistant
    • nonallergenic
    • circular motion
  17. Monitored anesthesia care (Conscious Sedation)
    • mode of delivery that facilitates the transition from inpatient recovery to early discharge
    • used with local or regional anesthesia for procedures outsite OR
    • Registered nurses with training can administer this type under direct supervision of a physician
    • relieves anxiety, provides analgesia and amnesia
    • pts remain responsive and breathe w/o assistance
  18. Choice of anesthetic
    • responsibility of ACP
    • factors considered:
    • pts current physical, mental, and emotional status
    • allergy and pain hx
    • expertise of the ACP
    • length, site, discharge plans
    • contraindications: pt refusal
  19. General Anesthesia
    • induced via IV(mainly)or inhalation & maintained by either 1 or a combo of the 2
    • a balanced technique-using adjunctive drugs to complement the induction
    • loss of sensation with loss of consciousness
    • skeletal muscle relaxation
    • no gag, cough, vomiting responses
  20. Inhalation Agents
    • cornerstone of general anesthesia
    • volatile liquids or gases
    • easy administration
    • rapid excretion
    • irritating effect on respiratory tract
    • complications: coughing, laryngospasm, bronchospasm, increased secretions, respiratory depression
  21. Regional anesthesia
    • loss of sensation to a region of the body w/o loss of cosciousness
    • local anesthesia injected into a central nerve or group of nerves that innervate a site remote to the point of injection
  22. Local anesthesia
    • loss of sensation without loss of consciousness
    • alters the flow of sodium into nerve cells thru cell membranes
  23. Ketamine(Ketalar)
    • commonly administered dissociative anesthetic
    • potent analgesic and amnesic
    • used in asthmatic pts bc promotes bronchodilation
    • increases heart rate to help with cardiac function in trauma pts
    • PCP derivative-causes hallucinations and nightmares
    • concurrent use of midazolam(Versed) reduces or eliminates hallucinations
  24. Spinal Anesthesia
    • injection of a local anesthetic into the cerebrospinal fluid found in the subarachnoid space, usually below the level of L2
    • produces autonomic, sensory, and motor blockade
  25. epidural block
    • injection of a local anesthetic into the epidural space via a thoracic or lumbar approach
    • sensory pathways are blocked but motor fibers remain intact
    • observe for hypotension, bradycardia, nausea, vomiting
  26. eldery patient considerations
    • onset, peak, and duration of medications are greatly altered- should be titrated
    • blood and fluid loss and replacement
    • hypothermia
    • pain
    • tolerance to surgical procedure and positioning
  27. Malignant Hyperthermia
    • rare disorder characterized with rigidity of skeletal muscles that can result in death
    • increase in body temp is not an early sign
    • succinylcholine(Anectine)- primary trigger
    • other factors- stress, trauma, heat
    • caused by calcium not leaving the cell
    • TX- prompt administration of dantrolene (Dantrium)
  28. Holding area
    • admission, observation, and discharge (AOD) area
    • waiting area inside surgical suite
    • identify and assess pt here b4 transfer to OR
    • minor procedures performed here-i.e. IV insertion, arterial lines, cast removal
  29. Admitting the pt
    • reassess pt and answer ?'s
    • review chart for any changes
    • ? last intake status
    • ensure correct pre-op med was given
    • cover pts hair to prevent shedding
    • prophylactic antibiotic given 30-60min before incision
    • remove hair around incision site
  30. Postioning the pt
    • ACP indicates when to position
    • musculoskeletal alignment
    • no undue pressure on nerves, skin over bony prominences, earlobes, eyes
    • adequate thoracic excursion
    • no occlusion of arteries, veins
    • modesty
    • respect individual needs, i.e. aches pain
  31. (True/False)
    The American Society of Anesthesiologists (ASA) physical status classification is based on the physiologic status of the patient with no regard to the surgical procedure to be performed.
  32. Type of anesthesia used for procedures outside the OR
    local or regional with MAC
  33. Adjuncts
    • drugs added to an anesthetic
    • to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or ANS control
  34. Nursing role during the Preinduction Phase of general anesthesia
    • complete pre-op assess.
    • confirm operative permits
    • complete "time-out"
  35. Nursing role during the Induction Phase of general anesthesia
    • Assist with applying monitoring devices
    • assist with airway mgmt
  36. Nursing role during the Maintenance Phase of general anesthesia
    • Adust pt position PRN
    • monitor pt safety
  37. Nursing role during the Emergence Phase of general anesthesia
    • Assist in placement of dressing
    • protect pt during full return of reflexes
    • prep pt for move to PACU
  38. Disadvantages to local and regional anesthetics
    • inadvertent vascular injection leading to refractory hypotension
    • dysrhythmias
    • inability to precisely match duration of action to duration of procedure
  39. Insulin
    • controls hyperglycemia
    • stimulates glucose uptake
    • inhibits glucose production
    • use cautiously in:renal/hepatic impairment. stress, infection
    • can cause: hypoglycemia
    • beta-blockers-may mask signs of hypoglycemia
    • corticosteroids-increase insulin requirements
  40. Narcan
    • an antidote for opioids
    • reverses CNS depression and respiratory depression
    • onset 1-5minutes, duration 45min
    • use cautiously in: cardiovacular disease
    • may cause: ventricular arrhythmias, hyper/hypotension
    • assess respirations, PR, BP, and LOC after admin
    • used to treat resp. depression but also reverses analgesia
  41. (midazolam) Versed
    • benzodiazepine
    • *induces amnesia effect
    • reduces anxiety pre/post-op
    • induce and maintain anesthesia
    • treat emergence delirium
    • supplement sedation in local & regional anesthesia
    • adverse effects: synergistic effect with opioids, increased risk for resp. depression, hypotension, tachycardia, prolonged sedation/confusion
    • interventions: monitor LOC, assess for mentioned adverse effects
  42. (enoxaparin) Lovenox
    • anticoagulant
    • prevents DVT and pulmonary embolism
    • use cautiously in: malignancy, ulcer disease, kidney/liver disease, bleeding disorders
    • causes: bleeding, anemia, dizzyness
    • interventions: assess for signs of bleeding to include fall in BP or Hct
  43. morphine sulfate
    • Opioid
    • induce and maintain anethesia, reduce stimuli from sensory nerves, analgesia during/after surgery
    • adverse effects: resp. depression, stimulation of vomiting, bradycardia, peripheral vasodilation, hypotension, constipation
    • interventions: assess respirations, SpO2, protect airway, may need to give antiemetic