INTRAOPERATIVE PHASE

Intraoperative Phase

- Transferred to OR-ends with the transfer to the recovery area.

• Transfer onto the operating table• Phases of anesthesia• Operative proceedure• Transfer from operating table to stretcher• Safe transport to post-operative area (PACU)

SURGICAL TEAM

• Surgeon• Anesthesiologist• Scrub Nurse• Circulating Nurse• OR techs

Surgical team

• Surgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patient’s care.

• Scrub nurse- (RN or Scrub tech )- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

Surgical team

• Circulating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.

Surgical team

• Anesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pt’s physiologic status and providing the best operative conditions for the surgeons.

• Other personnel- pathologist, radiologist, perfusionist, EVS personnel.

Nursing Roles:Staff educationClient/family teachingSupport and reassuranceAdvocacyControl of the environmentProvision of resourcesMaintenance of asepsisMonitoring of physiologic and psychological status

Elements of Aseptic Technique

*Sterile gowns and gloves.*Sterile drapes used to create sterile field.*Sterilization of items used in sterile field.

Surgical asepsis

• The absence of pathogenic microorganisms.• Ensure sterility• Alert for breaks• The practice of aseptic technique requires the

development of sterile conscience, an individual’s personal honesty and integrity with regard to adherence to the principles of aseptic technique.

Preanesthetic Preparation

• Avoidance of foods and drink prevents passive regurgitation of gastric contents

• Clients should typically continue medications up to surgery

• Consent must be received

Sedation

• Reduction of stress, excitement, or irritability and some suppression of CNS

• Typically used to relieve anxiety and discomfort during a procedure

• Residual effects include amnesia and letheragy

Types of Anesthesia

• RegionalLocalNerve blockEpiduralSpinal

• General

Spinal Anesthesia

• Injected into cerebrospinal fluid (approx L 3-5) subarachnoid space

• Indications -surgical procedures below the diaphragm-patients with cardiac or respiratory disease

• Advantages -mental status monitoring -shorter recovery• Disadvantages -necessary extra expertise -possible

patient pain• Contraindications -coagulopathy -uncorrected

hypovolemia

Spinal Anesthesia

• Involved medications -lidocaine -bupivacaine -tetracaine

• Patient assessment-continuous heart rate, rhythm, and

pulse oximetry monitoring-level of anesthesia

-motor function and sensation return monitoring

Spinal Anesthesia

• Complications-hypotension-bradycardia-urine retention-postural puncture headache-back pain

Spinal Anesthesia (Subarachnoid Block)

• Anesthesia: tip of xiphoid to toes• Risks:

– Loss of vasomotor tone– “Spinal Headache”– Infection, Rising anesthesia above diaphragm

• Nursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE

General Anesthesia

• Inhalation-Mask, Endotracheal tube (ETT) or Laryngeal managed airway (LMA)

• Intravenous• Combination

General Anesthesia: Inhalation Agents• Inhalation most controllable method; lungs act as passageway

for entrance & exit of agent• Gas Agents : Nitrous Oxide

– must be given with oxygen– require assisted to mechanical ventilation– frequently shiver– taken in & excreted via lungs– Examples: halothane, enthrane, florane…

Adjuncts to General Anesthesia• Hypnotics (Versed, Valium)

– also used for conscious sedation• Opioid Analgesics (morphine, Demerol)

– respiratory depression• Neuromuscular Blocking Agents

– Causes muscle paralysis– Examples: Pavulon, Succinycholine– What vital function is affected?

Potential General Anesthesia Complications

• Overdose (consider risk factors)• Hypoventilation postoperatively• Intubation related: sore throat,

hoarseness, broken teeth, vocal cord trauma

• MALIGNANT HYPERTHERMIA– Genetic predisposition– Triggered by anesthetics such as Halothane

Potential Intraoperative Complications

Nausea and vomitingAnaphylaxisRespiratory complications

Inadequate ventilation, airway occlusion, intubation of the esophagus, and hypoxia

HypothermiaMalignant hyperthermiaDisseminated Intravascular Coagulation

What are measures to prevent or treat these complications?

Nursing InterventionsCommunicating plan of careIdentifying nursing activitiesEstablishing prioritiesCoordinate care with team membersCoordinate supplies and equipmentControl environmentDocument plan of care

Intraoperative Nursing Care

• Risk of infection related to invasive procedure and exposure to pathogens.

• Risk for injury related to positioning during surgery.

• Risk of injury related to foreign objects inadvertently left in the wound.

• Risk for injury related to chemical, physical, and electrical hazards.

• Risk for impaired tissue integrity.

• Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status.

Nurses are responsible for managing six areas of risk:

Nursing Process Intraop Phase

• Intervention– Safety– Advocacy– Verification– Counting-instruments, sponges, needles

Altered Skin Integrity

• How many sutures?• Staples or sutures or

glue???

POSTOPERATIVE PHASE

• Postoperative- Begins with transfer to PACU and ends with the

discharge of the patients from the surgical facility or the hospital.

• Nursing InterventionsCommunicating pertinent information about surgery to

the PACU staff.Postoperative evaluation in clinic or home.

Nursing assessment in the Recovery Room

• Vital signs- presence of artificial airway, o2 sat,BP,pulse, temperature.

• Ability to follow command, pupillary response• Urinary output• Skin integrity• Pain• Condition of surgical wound• Presence of IV lines• Position of patient

Immediate Post-anesthesia Care

• Airway• Breathing• Circulation

How often should vital signs be assessed?

Postop SKIN Assessment“Altered Skin Integrity”

• Day 3 or so to Day 14 (or 21 or more)– Proliferation: fibrin strands form scaffold

• Collagen with blood = granulation tissue• Protect from damage or stress

– No lifting, heavy exercise, driving etc.• At risk for dehiscence or evisceration

• Day 15 (or weeks, months, years)– Scar is organized, less red, stronger– Max strength = 70 – 80%

Postoperative RESPIRATORY Assessment

• Impaired gas exchange or impaired airway clearance

• Risks: pneumonia, atelectasis• Assessment:

– Open airway– Pulse oximetry (what is normal?)– Check opioid use (why?)– Monitor quality & quantity of respirations

Postoperative RESPIRATORY Assessment

• Interventions:– Turn (also relates to

cardiovascular risk – any ideas?)

– Deep breathe & cough– Incentive spirometry– In-bed exercises (see text)– AMBULATION!!

Postop SKIN Assessment“Altered Skin Integrity”

• Wound healing– How is the face healing time-line different from

the foot?• OR to Day 2 (may 3-5)

– Inflammation vs. infection• redness, pain, swelling, warmth• skin held together by blood clots & tiny new blood

vessels– Avoid pressure/ be sure to splint

Postop CARDIOVASCULAR Assessment: Potential for hypoxemia

• Think (hypovolemic) shock (hemorrhage) – Assessment:

• Prevention of venous stasis – Who is at risk?– What should be done?

Avoiding Venous Stasis• Avoidance of positions

leading to venous stasis• In Bed Exercises• Antiembolism stockings• Sequential

Compression Device• When all is said &

done, AMBULATION is the best!

Postop NEUROLOGIC Assessment

• Assess cerebral function– Think elderly

• Assess motor/sensory function

Postop F & E Assessment

• Fluid Status – Intake– Output

• Why would a postop client need an IV??

Postop URINARY Assessment

• Anuria (define) • Urinary Retention

– Or Urinary retention with overflow• Differentiate

• Intervention:– Fluids– AMBULATION– Careful monitoring

Postop GI Assessment

• Nausea & vomiting• Assessment of peristalsis/paralytic ileus• Interventions:

– N/G tube, GI rest (NPO), AMBULATION• Postop Diets

– Why are clear liquids usually the first diet?– What does “advance as tolerated” mean?– What are nursing responsibilities??

Postoperative Diets • 1. Clear Liquid• 2. Full Liquid• 3. Soft• 4. Regular• Postop Diets

– Why are clear liquids usually the first diet?

– What does “advance as tolerated” mean?

– What are nursing responsibilities??

Postop SKIN Assessment“Altered Skin Integrity”

• R edness• E dema• E cchymosis• D rainage• A pproximation• Is a scar as strong

as the original skin?

The Ultimate in “Altered Skin Integrity”

• Risk factors:

-Dehiscence-Evisceration• Prevention:

-Wound Splinting-Abdominal binder-Diet

Nursing Diagnosis

• Ineffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, pain

• Ineffective breathing pattern- anesthetic and drug effects, incisional pain

• Acute pain• Urinary retention• Risk for infection

Postoperative Goals

• Re-establishment of physiologic equilibrium• Alleviation of pain• Prevention of complications

Postoperative Management

• Maintain a patent airway• Stabilize vital signs• Ensure patient safety• Provide pain• Recognize & manage complications

When caring for post-surgical patient, think of the “4 W’s”

• Wind: prevent respiratory complications

• Wound: prevent infection• Water: monitor I & O• Walk: prevent thrombophlebitis

Complications

• Respiratory- atelectasis, pulm. Embolus• Cardiovascular- venous thrombosis• Gastrointestinal-Hiccoughs, N/V,abd.

Distention, paralytic ileus, stress ulcer.• GU- urinary retention• Hemorrhage-slipping of a ligature(suture)• Wound infection-• Wound dehiscence and evisceration-

Postoperative Pain Control

• What is the definition of Pain?

• As nurses, what do we need to remember about the pain experience?

• What is the key reason to control postoperative pain?

THANK YOU