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The art and science of treating disease, injuries, and deformities by operation and instrumentation.
- May be performed to
Palliate: reduce symptoms and pain
Explore what's going on? sometime's symptomology. No Definitive diagnosis so you must open them up and see what's going on.
Prevent things from happening; problems
Cosmetic: especially in cali
The Perioperative Nurse
SAFETY is the main goal of the perioperative patient; many layers of safety
- Patient identification
- Surgical identification (in preop and immediately when pt goes into operating room)
=> text: complete preop assessment, check and confrim signed informed consent, complete surgical time out.
=>Induction: Assist with application of monitors and airway management. They monitor pt safety and position. Assist in dressing placement, protect pt during return of reflexes, prepare pt to move to PACU.
Identify: Right patient, right surgery, right body part, right physician (imp with various surgeons and rotating surgeons)
-Total RN CARE; nursing care through the continuum of the surgical experience- no lvns or CNAs. There must be a registered nurse in every single phase c:
- -RN responsible for providing care within the framework of the nursing process
- -Diff cert for nurses, cert in preop, intra and postop phase (crit care nursing-ICURNs); Certifications: CAPA, CPAN, CCRN (critial care-post op?), CNOR (intraop), ICRN
**Nursing Management: Plan of care-
=>Team approach: The patient act as the main team member, Surgeon, anest, surg tech, radiology diag tech, DMV, everyone works as a team. -at least 4 nurses working for one patient, and that one patient is asleep. Lucrative area. More aged nurses.
=> Multiple factor assessment pre-procedurally
- Client’s health and wellness
- Physical and psychsocial development
- Emotional state: If yiou're sooo anx before surgery then surgeon will cancel the surgery because that emotional state for that patient is so important for a positive outcome (of course if not urgent); must acheive that emotional stability
- => Family involvement: individual's must go home for recovery, someone has to take care of them at home. Those couple days after surgery is probably the roughest part. Make sure that individual is there. Cancelled surgeries if no one will be home.
**Phase 1: Role of the Preoperative Nurse
- Pre-Op Nursing Responsibilities-gather all the data, make sure everything is in place before that pt goes to surgery.
- Initial surgery is sched thru surgery dept or order of the floor and steps are made to ensure that pt meets certain criteria for standards of safety to allow for anesthesiologist to safely put pt to sleep, allowing for surgeon to safely cut into the pt.
- -Look at hemodyinamics and labs.
- => Preparation of patient for surgery--> Assembly of patient record (chart): Preop Diagnositic Tests
- Preoperative diagnostic tests:
- 1. Labs: PTT, PT (blood clotting factors b/c we're destroying defense mechanisms), WBCs (infection can go to site of surgery. For instance, pt with UTI and sched for Total Knee Rep, that pathogen can move into joint and VERY diff to eradicate due to no blood flow and antibiotic is diff to get into that area). H&H to make sure to anticipate blood loss. Fluids and Electrolytes (imp for anesthesiologist-looks at homeostasis; imp for EKG and cardiovasc.)
2. Electrocardiogram (EKG)-baselines; For 40 yrs old, it's required they have a baseline EKG because a lot of meds that put them to sleep are cardiotoxic
3. Chest X-ray (CXR): for pulm function, b/c we're putting pt to sleep and breathe for them. Diff for anesth to keep up with their breathing needs if no adeq pulm fn.
4. Pulmonary Function Tests: Forced Incentive Spirometer to see what their vital capacity is. => History and Physical (H&P): Surgeon, specialists, PCPMust be Primary Care Phys! Can't be a DO. OR DDS? (Dentist) MUST BE 30 DAYS UPDATED BEFORE THE SURGERY ITSELF.
- => Consents: must be written, signed by pt or pt represntative (minor's parent, person on Adv Directive or whoever they have the durable powr of attorney indicated)
- -state exact planned surgery, the surgeon, anesth, the risk/benefits, potential blood transfusion (consent must be signed). Surgical procedure, the surgeon
- Blood Transfusion
- Sterilization: If certain procedure is being sterilized, that consent must happen NO LESS THAN 72 HOURS BEFORE PROCEDURE; if earlier then it's not valid. Why? Change your mind, coercion, etc. Ex:Tubes tied, Vasectomy. Sign it 72 hours THEN you can have the surgery. Makes you don't reconsider.
- => Subjective Data
- -> Patient interview by preop nurse: May be performed over phone before admission, or to pt on flood, care nurse
- -detailed; Includes physical, emotional, cultural, and spiritual well-being or needs of the patient based on this surgery
- -History of previous surgery: when, how long it happened?
- ->Complications with surgery or adverse reaction to anesthesia: any rnxs to anest? post op healing probs? Post op pain? Intra op problems (diff going to sleep, waking up during surgery).
- Ask questions of surgical history
-Family history of complications with anesthesia; condition where pts can have allergic rnx to anesthesitia of hypermetabolic state-> increasing temp, "Malignant Hyperthermia".
Things that we should be doing as nurses. As body increases in temp, everything goes tight. "Tetany" Heart can't beat, no blood flow, we can't actually resusitate that pt until giving meds to stop that procedure. Pt can't test positive for this in blood if a family member in past that has had this reaction. It's like an internal allergy. In relationship to inhaled anesthesia. Anecdote: Dantreium.
- -Knowledge of proposed surgery and proposed anesthesia (informed consent): ask if they understand procedure and explain in their own words what type of procedure they're going into. Know the risks and benefits. We as nurses must assess to see how much education they have on procedure and if they aren't well informed then we need to send them back to surgeon b/c that pt can't be taken into surgery.-Recent illness? Flu, UTI, skin infection, how recent? Anything that hasn't been cured in the last week. Must have good health.
- -Past and current medical problemsChronic illnessesRecent cardiac or respiratory problems: if so, what? Are they resolved? what have they done to manage them?
- Neurological deficits
- Urinary or kidney disease* important b/c anest meds given are metabolized through these target end organs
- Liver disease
- Mobility difficulty: Ex: using walker before that ankle surgery.. or shoulNutritional status: Diet high in protein postoperative, Dietary habits. ; Have they had recent weight "change" in past month? Current nutritioinal status? Any specifc dietary needs? DO you get enough protein and iron if you're vegan that will be lost during surgery.
=> MedicationsCurrent useHerbal -see syllabus; states change of homeostatis. Over the counter (OTC)PRN's- certain ones could delay healing or prlong bleeding timeRecreational drug use: "how much do you use?" for LOC, Anesth needs to know the most b/c if it's with system, then it fights for those receptor sites so they need MUCH MORE anesth. meds to put them to sleep. Tell them to please not to use drugs within 24 hours because those drugs compete with the drugs we are going to give you to put you to sleep.
=> Allergies drugs food adhesive material (tape, band aid): because of dressings latex, etc.: gloves, and it's everywhere in that OR. Latex is airborne "spores in air". All tubings, things for the anesth. meds. have latex. They will be put in a non-latex room, with latex free equipment. usually one of the first procedures.Smoking, alcohol, and recreational drug (substance) use.
Smoking & Nicotine.. CO2
from Bicarb nicotine has strong affinity to hemoglobins so Oxygen has difficulty attaching to hemoglobin. More competitiion. Again, we ask pt to not smoke for 24 hours AT LEAST before surgery
competes with anest and pain medications, messes with homeostatis of glucose levels. Difficult to utilize. Tell them not to drink for 24 hours. Ask them about alchol use.. make sure it's specific.
rare disorder charcterized by hyperthermia with rigidity of skeletal muscle that can result in death, succinylcholine (Anectine) mixed with volatile inhalation agents is primary trigger along with stress, trauma, heaat. During General anesthesia or recovery process.
-An autosomal dominant trait
-fundamental defect: hypertmetabolism of skeletal muscle resulting in altered control of intracellular callcium leading to contracture, hyperthemia, hypoxemia, lactic acidosis and hyemodynamic/cardiac alterations
-Tachycardia, tachypnea, hypercarbia, ventricular dysrhythmias
-Definite treatment: Dantrium/Dantrolene
=> Pre-op instructions
- -give info about unit procedures; what they'll expect the min they walk into preop, all the players and all the phases. Unit Procedures
- Directions to facility
- => Pre-op instructions
- NPO: nothing by mouth 6-8 hours before procedure.
- Surgical Scrub: surgical will give them a kit to clean the area. Hibiclens. (ortho and heart cases)
- Colon Prep: No FOOD day before so only clear liquids. Something light if late procedure and can have breakfast.
- What to wear: no skinny jeans after knee procedure. xD Dress approp for post opWhat to bring: leave personal items at home, bring only phone, ID, insurance card.
- Post-op/discharge expectations: what to expect in recovery and phys therapy and pain management. They come in with so much pain, but they don't realize that first 72 hours, they will be in more pain than what they come in with.
**Patient Assessment (Intra Op)
=>Objective data (completed in Pre-op) Right before the surgery.
-Baseline vital signs: Temperature, pulse, blood pressure, respirations, oxygen saturation, pain (obtain pain goal), height and weight- imp for anesthesia which is weight base meds.
-Complete head to toe assessment-physical. Pay attention to the system that they have core morbidities in. Ex. Smoker-focus on lungs for any adventitious sounds.
-Diligent specific system assessment if patient has specific system abnormalities or chronic illness; E.g.. Patient has smoked for 30 years, assess lung sounds and respiratory effort to ascertain potential perioperative risks, and post operative complications
-Apply identification arm band, allergy band and blood product band as applicable, If we know the pt is going to need blood, they will go into lab and attach to pt the band. The band cannot be removed "Blood band" because blood has been crossed and screened specifically for them and kept in the blood bank. Don't put band in the extremity that is NOT having surgery.
- -Surgical and anesthesia consent signature-Dress patient in surgical attire: Head cover, Hospital gown. Allow patient to wear socks or provide surgical socks because theirs is dirty. Start intravenous lineInsert Foley catheter if applicable (usually after they're asleep in intra op)Apply anti-embolism stockings if applicable: teds or SCDsDraw labs if applicable (day of)Visit by Anesthesiologist, or Nurse Anesthetist if not done previously and mark the surgical site. Mark surgical site with permanent marker (MD must do): Must be a "YES" on the surgical site-TJC guidelines; usually on areas of lateralization.
- *Note: If the pt signs they're own consent then they are they're own witness. But if the person who signed is someone else, then that person should be in the room !
- => Patient education ABOUT Recovery room process
- *Show them in preop
- *Turn, cough, deep breathing (TCDB)Abdominal, chest splinting
- Pain management
- Postoperative ambulation: how to use crutches, walker
- Postoperative diet: what to expect about what they could have.
- Incision site care
=> Administer preoperative medications
**Administer preoperative medications
- ->Single or combination of drugs
- Sedative (Ativan)
- Amnesic (Versed): effects are the same as what they'd act like if they were drunk. Are they a crying or angry drunk? Decision making process is altered.
- Secretion reducers (Atropine):
- Pain control/management (Narcotics): preop pain
- Antiemetics (Reglan, Zofran, Inapsine): Fenergan, compazine...acts on diff receptor sites to control n/v
- -Antibiotics (variety depending on organism/allergies): started prop, must be given 30 mins before cut time. On call to OR: given immediately when called, if you don't know how long, must be given no later than 30 mins of cut time. If they already have an infection before surgery, can they still have surgery? Then preferrably wait... preop antibiotics tend to be same as postop antibiotics.
- -Routine medications: give instruction on what meds they can take on day of surgery. Especially the ones that maintain homeostatis to maintain baseline (cardiac, BP meds with sip of water at reg scheduled time) BUT stop blood thinners depending on duration or metabolic process (usually three days before surgery). Don't tell them to take diuretics b/c loss of water/volume.
- -BS meds: Oral meds may increase insulin and based on what they eat. SO if they don't eat, then they'll have hypoglycemia when they're intra op :( Tell them NOT to take oral antidiabetics.
- FOr insulin, they'll have to readjust, take to endocrinologist before they come in. IN preop, take Blood sugar and ask anesth if we should give them insulin. Sliding scale is based on food carbs and they won't be consuming anything.
-Note: Any anesthesia, they no foood!! :(
-Anti-thrombolitics: sometimes meds ordered prop to prevent chance of blood clot.
**Pre-op Check-list (in syllabus)
- ; preop starts and OR Nurse reviews that list.
- Pt. Identification
Consent completion (special consents: sterlilzation and blood consents)H & P
Allergies: and reactions. Is it true or side effect?
- NPO status: when was last time you had something to eat or drink? If you had a drink of water at within NPO range, then tell anesthesiologist and usually cancel that surgeryLast meds taken: last night? this morning? How much?
- Last voided/bm: If colon prep, must be clear yellow.
- Labs-current, abnormals notified to surgeon/anesth.
- Blood glucose (if diabetic) levels
Metal/Jewelry-electric caudery; that electricity arcs to that metal on pt or go throughs pt up to that metal and burn the pt. Use a grounding pad for metal within patient.. If you can't remove, then sign that consent and cover as much as we can with gauze and do the surgery..
**Phase 1 Nursing Diagnoses
- Knowledge Deficit Alterations in Comfort: Pain
- Risk for Infection
- Risk for Acute Confusion: especially with those amnesic, antianxiety meds
- Risk for Falls
- Risk for deficient Fluid Volume: tell them to hydrate well the day before! Alteration in Skin Integrity
-> Clicker Q: If a pt hasn't taken BP med the morning of surgery and BP high, Validate results and take manual BP on the other arm, IF still high, notify anesthesiologist (HOMEOSTASIS)
**Phase 2 -IntraOP- : Role of the Circulator
-makes sure everything is maintained equipment wise, sterility wise, everything is functioning in the OR.. THEY'RE NOT STERILE.
THE TWO NON-STERILE PEOPLE: ANESTHESIOLOGIST AND CIRCULATOR.
-goes into preop and in charge of taking from preop into the OR. Plans and coordinates intraoperative phase
Accepts patient from preoperative holding room: Patient identification, Surgical identification, body part marked?, Chart review (Surgical Check-list: Informed consent signed?, H&P, Diagnostics)
**Transfer to Operating Room from PreOP suite (Phase 2) .
- Use of gurney or wheel chair
- Wagon or crib (for children) or OR Nurse can handcarry that nurse
- Completed Chart
- Belongings-distributed; sometimes given to family member
- Family disposition- OR nurse tells family where to wait, and tells family member what happens after procedure is over
** Core Measures: Universal Protocol
Make sure that the correct surgery is done on the correct patient and at the correct location on the patient’s body. and that there is no errrors.
=> Conduct a pre-procedure verification processIncludes the pre-operative/pre-procedural checklist and family member that has signed for that procedure to happen. Involve the patient when possible
- =>Mark the procedure site (by surgeon)Involve the patient when possible
- To be done by the “licensed practitioner ultimately accountable for the procedure that will be present when the procedure is performed.”Marking is to be unambiguous, used consistently, and be done using permanently enough so it is visible after the skin prep and draping. "Indelible ink" to survive the surgical prep scrub. Have a written, alternative process in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site.
- => Perform a Time-Out before the procedure.-everyone must be in room:
- circulator starts it (states who they have validated by name band) surgeon, scrub tech, administer antibiotic
- Is standardized by the hospital, initiated by a designated team member, and involves the immediate members of the interdisciplinary procedure team.
- Done immediately before starting the procedure; right before cut time and documented by the circulator.
- => Another time-out is performed between procedure changes with the same patient. (if there is mulitple procedures)
- Must, at minimum, address correct pt. identity, correct site, and correct procedure.
- Must be documented.
**Role of Circulator
- Admission to the surgical suite
- Orientation to the physical environment: might be drugged by versed..
- Transfer to surgical table: Positioning/Safety straps, Warm blankets, Application of grounding pad, (give them more blankets
- -O.R suite is 15 degrees cooler /: ) Application of monitoring devices
- Assist anesthesiologist with induction of anesthesia and O2.Surgical site prep after time out and pt is asleep.
- Assists with gowning surgical teamAssists with draping the patient
- => Documentation Intraoperative record: Right patient, right surgery, right site,
- TIME OUT
- Course of surgery
- I & O
- Transfer to recovery room
- => Surgical Counts--Three counts: Before surgery begins, before first layer of closure, before last layer of closure-Instruments, Sponges, Sharps (needles and scalpels)--Additional counts
- -Change of surgical crew
- -Adding new surgical crew Supplies Team with
- Sterile Instruments: Sterile field medication management
- Reinforces preoperative teaching (pain control, TCDB, Dressings, Mobility, PACU expectations)
Assists in preparing/cleaning the OR
Observes for breaks in sterile technique: Keep 2ft distance from sterile field
Measures blood and fluid loss
- Assists with dressing of incision before discharge from OR
aaaaand Transfer to recovery room: Accompanied by Anesthesiologist, Detailed report to recovery room nurse
Role of Scrub Nurse/Scrub Tech: Surgical scrub
- Assists surgeon with giving them instruments. Usually RN or scrub tech program.
- Six minute hand and forearm scrub & hightech isogel
- Sterile attire and technique
- Setting up the surgical table and sterile field; make sure all the trays are there and sterile. Scrub tech can manipulate all the tables.
- -Drape and gown the patient
- Gowns/gloves surgeons
- Assists with draping patient
- Surgical count. They start it!
- Assists surgeon and assistant surgeon with instruments, suture material, anticipates surgeon’s needs prior to the surgeon (big thingg! Be a mind-reader) like a game of chess. Assists circulator with dressing the surgical incision at the end.
- Sends instruments to sterile processing; they're in charge.
**Other Members of the Surgical Team .
ASSISTANT TO SURGEON
ANESTHESIA CARE PROVIDER (ACP)
Writes postoperative ordersThe orders for caring for a pt post operatively are between the surgeon and the anesthesiologist. They maintain homeostasis so anything we need to regard vitals signs, those orders from anesthesiologist. If surgery and drains, nutrition and elimination orders come from surgeon. Most of discharge depends on the physcian.
- => Assistant to the surgeons
- Surgeon (another)
- PA (Physician assistant)
- RNFA: Nurse w/ Master's degree that has gotten "First Assistant" certificate; they can do the same role as PA: close, harvest, they just can't write orders.
- => Anesthesia Care Provider (ACP)-could be a nurse. Responsible for the homeostasis of the patient during surgery
- Determines type of anesthesia based on type of surgery and comorbidities and anxiety level.
- Writes recovery room orders for pain control and homeostasis management
- -determine final anesthetic care plan, insert/monitor IV access, confirm antibiotic prophylaxis, position pt appropriately for surgical procedure, administer appropriate drugs, monitor pts physiological status, reverse resideual neruromuscular blocking agents, assess for return of all protective reflexes, remove aireway assist devices.
- Assess pain
TYPES OF ANESTHESIA
- 1. General
- 2. Local
- 3. Monitored Anest. Care (MAC)
- 4. Regional
- given through IV and inhaled as well
- -Anesthesiologist should have given them versed before they get here so they feel loopy and not remember anything.
- -In OR: we oxygenate them with highflow. Hyperoxygenate them and Anesthesthisologist gives them meds to put them to sleep
- Then intubate them to give them inhalatiion type of anesthesia
- involuntary movements and change in vital signs as they go deeper into sleep (go down) and then this reverses as they start to wake up.
-can give paralytic: dependent on machine to breathe or less deep where they can breath but still give them oxygen. Surgery that requires significant muscle relaxation with no muscle movement: thoracic, abdominal. Lengthy surgery: they utilize a LOT of medication, definitely general used.
- Difficult position to be maintained: If on abdomen or side for lateral lobectomy or lithomy; pressure ulcers: anesthetist can rotate bed. Requires control of respirations
- Patient with extreme anxiety
- Patient who refuses local or regional medPatient who is unconscious
- -circulators role to see if a toe is wiggling.
Loss of sensation with loss of consciousness, combination of hypnosis, analgesia and amnesia, usually involves use of inhalation agents, skeletal muscle relaxation, Elimianation of coughing, gagging, vomitting, and symp ns responsiveness, requires advanceded airway management.
** Administration of General Anesthesia:: IV
-Barbiturates (seldom used b/c of better action for Diprivan/Propofol): Pentothal & Brevitol
-Non-Barbiturates: Propofol (Diprivan)- gold standard to put pt to sleep. Ideal for short outpatient procedures b/c of rapid onset of action, metabolic clearance, may be used for induction and maintenance of anesthesia. May cause bradycardia. monitor serum triglyceriaides for sedation > 24 hrs.
-Dissociative Agents (pediatrics): give IM when pt is scared: Ketamine (Ketalar)-puts them to sleep quickly but can give them hallucinations. Can be administered IV or IM, potent analgesisc and amnesic.
-Benzodiapines: Versed (the amnesics) This combined with prop is beautiful. Given IV, oral, liquid, lollipop
-Opiods- Fentanyl (for pain receptors and shoulder twitching)
-Muscle Relaxants (paralytics)
**Administration of General Anesthesia:: Inhalation
- => Volatile liquids: all cause skeletal muscle relaxaton
- Isoflurane: distinct smell
- Desflurane: fastest onset; used in ambulatory settings
- Sevoflurane: distinct smell especially as exubated and exhaling in oxygen mask.
- => Gases
- Nitrous oxide (N2O)
- Oxygen Therapy
**Nursing Considerations for General Anesthesia
Provides an unconscious state NOT pain management
Slow return of major body systems: brain but not all vitals quickly, return for bowel, urinary fn, musculoskeletal use
- GI tract
- Can cause delayed awakening and emergence delirium (we put them to sleep artificially and we wake them up artificiallly so brain panics and sends signals and fighting -> hitting and kicking. Most often seen in teenage and preteen boys. And men with high stress jobs. PAD the side rails! Hit them with antianxiety and opiods also) Must consider age, wellness or illness state of patient
2. Local Anesthesia
-num up any skin surface. Loss of sensation w/o loss of consciousness. Induced topically or via infiltration, intracutaneously or subQ. Topical applications may be aerosolized or nebulized.
- Block initiation and transmission of electrical impulses (numbing agents): injection or cream
- EMLA cream
-huge needle to numb joint to use less narcotics afterwards in recovery.
3. Monitored Anesthesia Care (MAC)
-light form of anesthesia so pt goes to sleep but doesn't lose respiratory drive, pretty much in b/w stage.
-propofol/Diprivan: ACP must be there, not just a regular RN. Tll pt we have back up don't worry.
- OR higher doses of opiods and antianxiety (higher levels)- versed and fentanyl for GI procedures.
-Propofol is nice b/c it's quick; fall asleep in mid conversation and half life is just as quick! No drugged feeling, once you wake up, you're refreshed (why MJ loved it.)
- Provides maximum relaxation/sedation without breathing assistance
- Given IV
- Versed/Fentanyl most commonly used
- RN has special competency to care for patient with conscious sedation
- Administration of Propofol (Diprivan)
- By Anesthesia Care Provider only
- Used widely in gastrointestinal cases: Sigmoidoscopy, Colonoscopy
Similar to general, sedative, anxiolytic and/or analgesic meds used, Does not usually involve inhalation agents, pts less responsive and may require aiway managment, provides maximum flexibility to match sedation level to pt needs and procedureal requirements, often used in conjuction with regional or local anesthesia, often used for minor therapeurtic and diagnosis procedures (eye surgery, colonscopy)
- epidural & Bier block
- to that nerve route, administer anesthetic to put those nerves to sleep. Any nerve route along spinal branch.
Flood venous system with anesthetic that puts upper body to sleep.
- **Regional Nerve Block
- Injections of local into nerve or nerve group
- -can stay in place, can go post operatively with that line in that place wih a pump continuously giiving medication over certain amt of time, use for total knees and hips. Allows for use of less narcotics.
- -Used for some gyn cases.
loss of sensation to a region of body without loss of consciousness, involves blocking a specific nerve group with local anesthetic administration. Includes spinal, caudal, epidural anesthesia and IV and peripheral nerve blocks (sciatic, supraclavicular, etc)
- Intraoperative anesthesiaPostoperative analgesia
Also referred to as Spinal anesthesia Epidural anesthesia
**Nurse's role is to make sure equipment is ready for anesthestist to use. -anesth responsible for response and make sure the antidote is avalabe!
Agents that enhance inhalation agents
- => Opioids: Fentanyl, Dilaudid, Morphine. Induce and maintain anesthesia, reduce stimuli from sensory nerve endings, provide analgesia during surgery and recovery in pacu.
- -adverse effects: respiratory depression, stimulatings vomiting,
=> Neuromuscular blocking agents (non depolarizing)
- => Benzodiazepines: diazepam (Valium), midazolam (Versed), lorazepam (Ativan)-Reduce anxiety prop and post op, induce and maintain anesthesia, induce amnesisa, treat emergence delirium. Supplement sedation in local and regional anesthesia and MAC.
- -Adverse Effects: Synergist effect with opioids, increae resp depression, Hypotension, tachycardia, prolonged sedation or confusion-Reverse with flmazenil (Romazicon)
Atracurium besylate (Tracrium), mivacurium chloride (Mivacron), vecuronium (Norcuron) (We have a reversal for this, so used more than depolarizing)
- - effects are usually reversed toward end of surgery by giving anticholinerterase agents.
- 2. Depolarizing: succinylcholine (Anectine): No chemical reversal. Must wear off & Rapid onset, short acting Facilitates endotracheal intubation, promote skeletal muscle relaxation (paralysis) to enhance access to surgical sites.
- http://www.emsvillage.com/articles/article.cfm?id=61 => Antiemetics: Metaclopramide (Reglan), ondansetron (Zofran), compazine, phenergan --> to avoid sickness in stomach. If pt has known rxn to anesthetics or history of motion/carsickness. -Scopalamine patch behind ear the night before if knowing the rxn is bad.
problem is pt is asleep so how do we know? Redness and vital sign change !
- Malignant Hyperthermia- Inhalation agen causes rxn in body where it goes into hypermetabolism; Dantreium is given to reverse it; ncreases tempterature so Iced Normal Saline.
- Inherited condition
- Hyperthermia, hyperkalemia, cardiac dysrhythmiax, and muscle rigidity
- Combination of Anectine and inhalation agent
- Treatment Dantrium
- Iced NS rapid infusion
**Intra-Operative Nursing Diagnoses
- Fluid Volume Deficit or Excess
- Alteration in Tissue Perfusion
- Impaired Gas Exchange
- Risk for Ineffective Airway Clearance, secondary to aspiration pneumonia a.e.b. aspirated vomitus (that's why we want them in empty stomach)Risk for Perioperative-Positioning Injury (don't want to press on a nerve)
**Post Anesthesia Care Unit (PACU) admission:
- Report from Circulator and ACP-transfered via anest and circulator.
- Patient past medical history and meds
- Course of surgery
- Estimated blood loss (EBL)
- Current IV infusion (Total intake)
- Medications-last meds given to pt; Pain meds in surgery- when was that last narcotic given? Were antiemetics given? Review of anesthesia post-op orders& Circulator adds in any info that was forgotten.
**Initial PACU Assessment
Main focus: ABC’s, Pain, Vital signs, Surgical site, Reorient patient (tell them where they are)
=> Aldrete score (10 pts) "REturn to homeostatis recovery system so that they can move out to recovery); each is worth two. Must reach 8 or above. Less than 7, they CANNOT leave as standard of practice.
- -O2 saturation: greater than 92% on room air-Circulation (B/P within baseline)
- *note: PACU is like ICU (1:2 pts ratio); pacu nurse has to stay on Med Surge floor for that first sign of vital signs after giveing report over phone. Bedside report also.
- Then complete Full head to toe assessment: Neurological, Pain (continual) and detailed for comobities and system that was surgically repaired. Anticipating Emergence delirium (agitation)
- Reorientation (continual)
- Cardiac: see EKG continuously, checking pulses especially if surgery on extermities, Hemodynamic monitoring, Pulses/Peripheral circulation
- Respiratory: -assess lung sounds, Lung sounds post surgery, Encourage deep breathing and coughing (should be started in preop and continue them in post op and institute incentive spirometer in pacu)
- Abdominal-listen to Bowel sounds (hypoactive or absent) especially if you just did GI surgery
- Urinary System: Fluid balance, may or may not have Foley Catheter, bladder irrigation (start in recovery room)
- Musculoskeletal and circulation in extermities; Mobility, Turning, ROM
- Integumentary: Surgical site, Bony prominences-make sure no red areas(age, length of surgery)
- IV fluid: Fluid type, rate, amount left in bottle (LIB); Anest will acount for amount of IV fluid they infused during surgery and you will start with back up fluid that was left for the recovvery process. Mostly given lactated ringers and then post op flluids prescribed by surgeon.
- tDependent upon procedure and condition of patient
- Vital signs
- Surgical site
- Goal is to identify actual or potential patient problems as a result of anesthesia or the surgical intervention
**Common PACU problems
- =>Cardiovascular SystemHypotensionHypertensionArrhythmias-anticipate ectopic beats
- =>Nervous SystemEmergence delirium potential
- Delayed awakening: takes a while for pt to wake up not able to metabolize medicine quick enough. May need reversal agent for all antianxiety and narcotics (be careful b/c it will bring back postop pain and activating pain receptor site soo try antiinflammatory but opioid won't work)
- => Respiratory: Airway compromise Airway obstruction Hypoxemia Atelectasis Hyperventilation Bronchospasm Laryngospasm
- -breathing treatments, reintubating iif we can't oxygenate the pt.
- => Gastrointestional tract:
- Nausea and vomiting
- Anesthetic agents
- Type of surgery
- Gender: female more than males
- History of N&V with other surgery
- Motion sickness
- also neuromuscular disorder
- Increase risk of aspiration
- => Pain
- Prolongs stay in PACUFearful by patient-impt to discuss pain goals with patient!
- => Hypothermia
- -Core temp < 96.8Cold roomInternal organ exposureOrthopedic SurgeryIncreased risk among elderly, debilitated or intoxicated-Use warming blankets: hot air blown into blowup mattress
=>Pain Initiate PCA Pump
- =>Circulation Apply pneumatic stockings if vte ordered
- -> Respiratory
- Instruct patient on use of Incentive Spirometry
- Instruct patient on TCDB especially if longer than two hours; don't want to increase intracranial pressure
- Instruct patient on chest/abdominal splinting
=> Medications as ordered Antibiotics: for the first 24 hours or else you increase MRSA risk. Antiemetics
- => Integumentary
- PositioningDressing assessment/reinforcement
**Discharge from PACU to Home Discharge Criteria
- –Ambulatory centerAll PACU criteria met
- Aldrete Score > 8
- No Intravenous (IV) narcotics for last 30 min;
- -If they're going home, cannot have IV narcotics within the last 30 minutes because of respiratory depression risk!
- Eating and drinking: not forced because they may get sick
- Voiding (surgeon/procedure specific)Able to ambulate: given them instruction and they must be able to demonstrate
- Accompanied by responsible adult: can't drive after anesthesia or operate machinery for 24 hours or sign legal documents
- Patient understanding of discharge instructions
**Discharge from the PACU to Hospital FLOOOOR.
- Discharge criteria for admission to M/S unit
- Patient awake (return to baseline neuro status)
- V/S stable
- No excessive bleeding
- No respiratory depression
- O2 Sat >90% (with or without oxygen) Pt. disposition is based on acuity (how much nursing care a pt needs), access to care, potential for post-op complication (determines what level of care they need)
**Transfer of patient from PACU to M/S Unit
- Report from PACU RN that accepts pt, pacu stays for first set of vitals aand transfer to bed. Pacu and accepting nurse look over incision site.
- Transfer to room
- Transfer to bed
- 1st set of vital signs-standard of care: Q15x4, Q30x4, Q1H x 4 because of complications of bleeding, surgery and anesthesia
Surgical site inspection including drains Document transfer by transfer nurse. Post-op review of orders with PACU RN
- Floor RN to complete a head to toe assessment with emphasis on area of surgical intervention
- Begin discharge planning
**Floor Admission Head to Toe Assessment
Use preoperative head to toe assessment as your baseline
- Neurological: LOC, orientation, pupils, ROM, pain, Anxiety and depression
- Respiratory: TCDB, I/S, abdominal or chest splinting
- Cardiac: Heart sounds, chest pain, pulses, peripheral circulation, Fluid status, presence of DVT
- Syncope: as a nurse, you need to be tehre for the first time they move from bed to bathroom, anticiipate orthostatic hypotension. Postural hypotension
- Gastrointestinal System: Listen to BS in all 4 quads, Presence, frequency, characteristics, flatus, Palpate abdomen: Soft, nondistended, Firm, distended,
- Progression of diet: clear to full to soft to regular!Nursing Interventions: ambulation, stool softeners, anti-flatulence, Harris flush, NG tube insertion to decompress
**Skin: Wound assessment (REEDA assessment)
-Wound dehiscence: Presence of hematoma or seroma
=> Dressing changes: Reinforcement of dressing1st dressing change done by surgeon unless ordered otherwise; if bleeding on that first dressing change, document and outline! Check vitals first!!
**Post op Temperature
- Hypothermia initially
- Hyperthermia: Mild, Moderate, High, Septicemia
- -possible after 12 hours because of inflammation and notify above certain pt told by surgeon.
- -high is poteiintal for septic reaction :(
: frequent temps, assess wound for REEDA, antipyretic, blood cultures, poss. CXR (chest xray)
**Surgical Pain Management: Pain Assessment
=>Severe first 24-48 hours post-op "Later", NEED pain control continuously, sell it. Narcotic analgesic: IV, Intramuscular (IM), Patient Controlled Analgesic (PCA), epidural or spinal medication
- => After 48 hours with normal recovery
- Transition from narcotics to non narcotics.
- Non-narcotic analgesic: AcetaminophenNon-steroidal anti-inflammatory" Ibuprofen, Toradol Medicate before activity
- Side effects of medication
Written information on drug prescriptions:
Type, dosage, timing, route side effectsContinuation of home medications
Written information reinforces verbal information
Home Health consultation
Family support and careWheel chair to awaiting car
- Documentation at discharge
- Time dischargedDischarged via wheel chair (w/c) accompanied by familyDischarge information given, patient verbalized understanding, demonstrated Jackson Pratt (JP) drain emptying, wound care, safety in ambulation
- Pain status at discharge
=> Herbal products:
-Avoid gingseng: increase BP
-Avoid garlic, vit E, ginkgo anf fish oil: increase bleeding
- Avoid kava and valerian: excess sedation-avoid multivit on day of surgery
CIRCULATOR VS SCRUBBED
=> Circulator duties: Asceptic technique, prepares room, conducts preprocedure verification process, verififies and implements ordered SCIP orders (drug admin, SCDs, patient warming), plans/coordinates intraop care, participates in application of monitoring devices and insertion of invasive lines, assists with transferring and positioning pt, assists w/ induction of anesthesia, participates in surgical time out, documents intraop care, measure blood, urine output and fluid losses. Maintains accurate count of sponges, accompanies pt to PACU and hand off report to PACU nurse.
=> Scrubbed: STERILE. Reviews anatomy, assists in prepping OR, surgical arm scrub, organizes sterile equipment, assists w/ draping, surgical time out, passes and anticipates instruments need by surgeon, maintains accurate count of sponges, monitors aseptic technique in self and other, keeps track of irrigation solutions use for calculation of blood loss. Accepts/verifies/reports medications used by surgeon or acp
IV opioids are the fastest reliefPCA best sustained relief
During 1st 48 hours of post op, opiiods required for pain