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Chapter 17 Care of Intraoperative Patients
Terms in this set (115)
The intraoperative period
-begins when the patient enters the surgical suite and ends at the time of transfer to the postanesthesia recovery area, same-day surgery unit, or the intensive care unit. The main concerns of perioperative nurses are the safety and advocacy for the patient during surgery
-a physician who assumes responsibility for the surgical procedure and any surgical judgments about the patient.
The surgical assistant
-might be another surgeon (or physician, such as a resident or intern) or an advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA), or surgical technologist. Under the direction of the surgeon and within the legal scope of practice for each state, the assistant may hold retractors, suction the wound (to improve viewing of the operative site), cut tissue, suture, and dress wounds.
a physician who specializes in giving anesthetic agents.
A certified registered nurse anesthetist (CRNA)
a registered nurse with additional education and credentials who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist.
The anesthesia provider
gives anesthetic drugs to induce and maintain anesthesia and delivers other drugs as needed to support the patient during surgery.
The anesthesia provider monitors the patient during surgery by assessing and monitoring:
•The level of anesthesia (i.e., by using a peripheral nerve stimulator or electroencephalogram [EEG] bispectral analysis)
•Cardiopulmonary function (using electrocardiographic [ECG] monitoring, pulse oximetry, end-tidal carbon dioxide monitoring, arterial blood gases [ABGs], and hemodynamic monitoring via arterial lines and/or pulmonary artery catheters)
•Capnography (monitors ventilation for non-intubated patients)
•Intake and output
-Depending on the patient's needs, anesthesia personnel give IV fluids, including blood and blood products.
uses clinical decision-making skills, develops a plan of nursing care, and coordinates care delivery to patients and their family members.
Holding area nurses
work in those operating suites that have a presurgical holding area next to the main ORs. The patient waits in this area until the OR is ready. The holding area nurse coordinates and manages the care while the patient is in this area. Responsibilities include greeting the patient on arrival, reviewing the medical record and preoperative checklist, verifying that the operative consent forms are signed, and documenting the risk assessment. This nurse also assesses the patient's physical and emotional status, gives emotional support, answers questions, and provides additional education as needed.
Circulating nurses or "circulators"
are registered nurses who coordinate, oversee, and are involved in the patient's nursing care in the OR. The circulating nurse's actions are vital to the smooth flow of events before, during, and after surgery. He or she is responsible for coordinating all activities within that particular OR. The circulator sets up the OR and ensures that supplies, including blood products and diagnostic support, are available as needed. All anticipated equipment is gathered and inspected by the circulator to make certain that it is safe and functional before the surgery. Depending on the procedure and position required, the circulator makes up the operating bed (OR table) with gel pads (to prevent pressure ulcers), safety straps and armboards (for patient positioning), and either heating pads under the sheets or disposable warming blankets placed over the patient as indicated (to prevent hypothermia)
If there is no holding area nurse
the circulator assumes the responsibilities of that nursing role as well. Even when there is a holding area nurse, The Joint Commission's National Patient Safety Goals (NPSGs) require that the circulator also greets the patient and reviews findings with the holding area nurse.
The circulator then may assist
with additional positioning, insert a Foley catheter if needed, apply the grounding pad, test equipment, and "prep" (scrub) the surgical site before the patient is draped with sterile drapes.
-Depending on facility policy, the circulating nurse may record drugs, blood, and blood components given. (This also may be a function of the anesthesia provider.)
Before the procedure is over, the circulating nurse completes documentation in the OR and nursing records, including the presence of drains or catheters, the length of the surgery, and a count of all sponges, "sharps" (needles, blades), and instruments. He or she notifies the postanesthesia care unit (PACU) of the patient's estimated time of arrival and any special needs.
Throughout the surgery, the circulating nurse:
•Protects the patient's privacy
•Ensures the patient's safety
•Monitors traffic in the room
•Assesses the amount of urine and blood loss
•Reports findings to the surgeon and anesthesia provider
•Ensures that the surgical team maintain sterile technique and a sterile field
•Anticipates the patient's and surgical team's needs, providing supplies and equipment
•Communicates information about the patient's status to family members during long or unique procedures
•Documents care, events, interventions, and findings
Scrub nurses or scrub persons
-set up the sterile table (Fig. 17-2), drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Knowledge of the surgical procedure allows the scrub person to anticipate which instruments and types of sutures the surgeon will need. Anticipating these needs reduces the duration of anesthesia for the patient. In addition, the surgeon's anxiety and tension are reduced when the scrub nurse or person is familiar with the procedure and can anticipate and respond accordingly.
🌟the scrub person (with the circulating nurse)
maintains an accurate count of sponges, sharps, and instruments and amounts of irrigation fluid and drugs used.
operating room technicians (ORTs) or surgical technologists
A specially trained person who is not a nurse may perform the scrub role. Often certified surgical technologists (CSTs) are used in the OR.
-may be in charge of a particular type of surgical specialty (e.g., orthopedic, cardiac, ophthalmologic) and are responsible for nursing care specific to patients needing that type of surgery.
-assesses, maintains, and recommends equipment, instruments, and supplies used in that specialty.
laser specialty nurse or a laser nurse coordinator.
If the facility uses laser technology, a nurse specially trained in the use, care, and maintenance of the laser is needed.
All personnel must observe safety measures (e.g., wear eye shields, read door signs) during laser procedures to prevent injury to the patient and staff
Laser is an acronym
-for light amplification by the stimulated emission of radiation
A laser gives off a high-powered beam of light that cuts tissue more cleanly than do scalpel blades.
This process creates intense heat, rapidly clots blood vessels or tissue, and turns target tissue (e.g., a tumor) into vapor.
used to prevent hypothermia
Blankets or warming units
The scrub and circulating nurses together
-ensure a correct count of surgical instruments, sharps, and sponges. Counts are performed before the procedure, during the procedure as items are added or at the time personnel are relieved from that assignment, at closure of the first layer of the surgical wound, and immediately before complete skin closure
A cool room temperature in the OR
(between 68° and 73° F [20° and 23° C]) with low humidity (20% to 60%) is optimal.
The surgical suite is located
out of the mainstream of the hospital and near the PACU and support services (e.g., blood bank, pathology, and laboratory departments).
The surgical area is divided into three zones
—unrestricted, semirestricted, and restricted—to ensure proper movement of patients and personnel.
Minimally invasive surgery (MIS)
Once used only for minor procedures and joint surgery, MIS is the preferred technique for many types of surgery, including cholecystectomy, cardiac surgery, splenectomy, and spinal surgery. It is even being used for cancer surgeries, such as the removal of a lung lobe (lobectomy) or even the entire lung (pneumonectomy) and colectomy. Research has verified many benefits of MIS, including reduced surgery time for some surgeries, smaller incisions, reduced blood loss, faster recovery time, and less pain and other discomfort after surgery.
MIS involves making one or more small incisions in the area of the surgery and placing an endoscope through the opening. An endoscope is a tube that allows viewing and manipulation of internal body areas (Fig. 17-4). Some endoscopes also magnify the view. These instruments may be rigid, semirigid, or flexible. Some have light sources, whereas others require that a separate light source be inserted into the surgical area. Endoscopes have different names and shapes for different surgical purposes. For example, laparoscopes are used for abdominal surgery, arthroscopes are used for joint surgery, and ureteroscopes are used for urinary tract surgery.
-An important part of MIS for abdominal surgery, pelvic surgery, and surgery in some other body cavity areas is injecting gas or air into the cavity before the surgery to separate organs and improve visualization.
-may contribute to complications and patient discomfort. It is one factor that is considered when deciding whether to perform a procedure by traditional "open" surgery or by endoscopy.
Many gynecologic, urologic, and cardiovascular procedures are being performed by using robotics. The robotic system consists of several components (Fig. 17-5). These include a console, surgical arm cart, and video cart. Initially, the surgeon inserts the required instruments and positions the articulating arms; he or she then breaks scrub and performs the surgery while sitting at the console. A three-dimensional (3-D) view of the patient's anatomy provides the surgeon with precise control and dexterity. The vision cart holds the monitors, cameras, and recorder equipment. This new technology requires a perioperative robotics nurse specialist who provides education for patients and family and training for members of the surgical team.
Mechanical trauma and thermal injury are two categories of injury that a patient can incur during MIS and robotic surgery (Ulmer, 2010). One limitation for both minimally invasive surgery and robotic surgery is the cost of special equipment and OR setting. In addition, surgeons require lengthy training and practice periods to become proficient in even one procedure performed using these endoscopic methods
Hands of surgical personnel
-may be cultured on a regular basis to determine the potential for nosocomial (hospital-acquired) infections and to identify sources of pathogens. Further interventions or cultures are needed if quality reports (e.g., through the facility's quality improvement program) indicate a problem. Routine cultures are usually obtained every 3 to 6 months. Surgical attire and the surgical scrub help prevent contaminations.
mask, eyewear, gloves, gown, and shoe covers
Typical attire for all scrubbed personnel
Note complete hair covering, eye shields, mask, sterile gloves over the sleeves of the sterile gown, and shoe coverings. Note that when not in use, the hands are typically folded in front of the body, never below the waist.
Team members who are not scrubbed
A broad-spectrum, surgical antimicrobial solution is used for the surgical scrub. Plain or antimicrobial soap is used for washing hands immediately before the surgical scrub. Vigorous rubbing that creates friction is used from the fingertips to the elbow. The scrub continues for 3 to 5 minutes, followed by a rinse. During the rinse, hands and arms are positioned so that water runs off, rather than up or down, the arms (AORN, 2010p). After scrubbing, personnel enter the OR with their hands held higher than the elbows and thoroughly dry their hands and forearms with a sterile towel. This person is then assisted into a sterile gown ("gowning") and puts on sterile gloves ("gloving"). Newer, alcohol-based surgical scrub agents may or may not require the use of water. Operating room personnel wash and dry their hands with soap and water before applying the agent to their hands and forearms, rubbing thoroughly until dry.
The areas of the surgical gown considered sterile
are the front of the gown from the chest to the level of the sterile field. The entire sleeves of the gown are considered sterile from 2 inches above the elbow to the cuff. The back of the gown is not considered sterile because it cannot be consistently seen by the wearer. Only when they are properly scrubbed and attired do members of the surgical team handle sterile drapes and equipment.
The word anesthesia means
"negative sensation." Anesthesia delivery is a precise science. It requires the skill of an anesthesiologist, a certified registered nurse anesthetist (CRNA) working under the direction of an anesthesiologist or another physician, or an anesthesiologist assistant (AA—similar to a physician assistant) working under the direction of an anesthesiologist.
an induced state of partial or total loss of sensation, occurring with or without loss of consciousness. The purpose of anesthesia is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve a controlled level of unconsciousness. Anesthesia providers use a separate anesthesia record for documentation.
Patient health problems are major factors in the selection and dose of anesthetic. Selection is also influenced by:
•Type and duration of the procedure
•Area of the body having surgery
•Safety issues to reduce injury, such as airway management
•Whether the procedure is an emergency
•Options for management of pain after surgery
•How long it has been since the patient ate, had any liquids, or had any drugs
•Patient position needed for the surgical procedure
•Whether the patient must be alert enough to follow instructions during surgery
•The patient's previous responses and reactions to anesthesia
The scrubbing, gowning, and gloving process
A, The surgical scrub. B, Rinsing. Note the water falling off the hands and arms. Also note the foot-operated handle that controls the water flow. (After scrubbing and rinsing, the scrub nurse dries his hands and arms with a sterile towel inside the operating room and then is assisted into a sterile gown.) C, The scrub nurse prepares sterile gloves. Note that the scrub nurse's hands are inside the sleeve of the gown and that he is touching the sterile gloves only with the sterile sleeve. D, The scrub nurse puts on his first sterile glove while the sterile gown is being tied in the back. Note again that his hand never emerges from under the sterile sleeve. E, The scrub nurse puts on his second sterile glove.
is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system (CNS). This state can be achieved with a single agent or a combination of agents. General anesthesia depresses the CNS, resulting in analgesia (pain relief or pain suppression), amnesia (memory loss of the surgery), and unconsciousness, with loss of muscle tone and reflexes. The patient is unconscious and unaware. This type of anesthesia is used most often in surgery of the head, neck, upper torso, and abdomen. It may also be used when patients cannot cooperate.
Most controllable method
Induction and reversal accomplished with pulmonary ventilation
Few side effects
Must be used in combination with other agents for painful or prolonged procedures
Limited muscle relaxant effects
Postoperative nausea and shivering common
Rapid and pleasant induction
Low incidence of postoperative nausea and vomiting
Requires little equipment
Must be metabolized and excreted from the body for complete reversal
Contraindicated in presence of liver or kidney disease
Increased cardiac and respiratory depression
Retained by fat cells
Minimal disturbance to physiologic function
Minimal side effects
Can be used with older and high-risk patients
Drug interactions can occur
Pharmacologic effects on the body may be unpredictable
Regional or Local ANESTHESIA
Gag and cough reflexes stay intact
Allows participation and cooperation by the patient
Less disruption of physical and emotional body functions
Decreased chance of sensitivity to the agent
Decreased intraoperative stress
Difficult to administer to an uncooperative or upset patient
No way to control agent after administration
Absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose
Increased nervous system stimulation (overdose)
Not practical for extensive procedures because of the amount of drug that would be required to maintain anesthesia
Reflexes remain intact
Decreases chance of adverse reactions
Decreased intraoperative stress
No way to control depth of anesthesia
Not used in long or extensive procedures
May not be appropriate for an anxious patient
Reflexes remain intact
Requires patient cooperation
Requires special training
Stage 1 (Analgesia and Sedation, Relaxation)
Begins with induction and ends with loss of consciousness.
Close operating room doors, dim the lights, and control traffic in the operating room.
Avoiding external stimuli in the environment promotes relaxation.
Patient feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic.
Position patient securely with safety belts.
Using safety measures in stage 1 prepares for stage 2.
Hearing is exaggerated.
Keep discussions about the patient to a minimum.
Being sensitive to the patient maintains his or her dignity.
Stage 2 (Excitement, Delirium)
Begins with loss of consciousness and ends with relaxation, regular breathing, and loss of the eyelid reflex.
Avoid auditory and physical stimuli.
Sensory stimuli can contribute to the patient's response.
Patient may have irregular breathing, increased muscle tone, and involuntary movement of the extremities during this stage.
Protect the extremities.
Safety measures help prevent injury.
Laryngospasm or vomiting may occur.
Assist the anesthesiologist or CRNA with suctioning as needed.
Adequate suctioning of vomitus can prevent aspiration.
Patient is susceptible to external stimuli.
Stay with patient.
Staying with the patient is emotionally supportive.
Stage 3 (Operative Anesthesia, Surgical Anesthesia)
Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital functions.
The jaw is relaxed, and breathing is quiet and regular.
The patient cannot hear.
Sensations (i.e., to pain) are lost.
Assist the anesthesiologist or CRNA with intubation.
Place patient into operative position.
Prep (scrub) the patient's skin over the operative site as directed.
Providing assistance helps promote smooth intubation and prevent injury.
Performing procedures as soon as possible promotes time management to minimize total anesthesia time for the patient.
Stage 4 (Danger)
Begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death.
Respiratory muscles are paralyzed; apnea occurs.
Pupils are fixed and dilated.
Prepare for and assist in treatment of cardiac and/or pulmonary arrest.
Document occurrence in the patient's chart.
Teamwork and preparedness help decrease injuries and complications and promote the possibility of a desired outcome for the patient.
An example of balanced anesthesia
is the use of thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation. Many combinations are possible, and selection is based on the individual patient and the specific surgical procedure
🌟Malignant hyperthermia (MH)
is an acute, life-threatening complication of certain drugs used for general anesthesia. The reaction begins in skeletal muscle exposed to specific agents, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature.
🌟Onset of MH
may occur immediately after induction of anesthesia, several hours into the procedure, or, rarely, even after the anesthetic has been terminated. Clinical features reflect the increased muscle calcium level and the greatly increased body metabolism. Manifestations include tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine). The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Extremely elevated temperature, as high as 111.2° F (44° C), is a late sign of MH. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed. Dantrolene sodium, a skeletal muscle relaxant, is the drug of choice along with other interventions.
The AORN recommends that all operating rooms have a dedicated MH cart containing
drugs for management (normal saline, dantrolene, sodium bicarbonate, insulin, 50% dextrose, lidocaine, and calcium chloride), a protocol card listing interventions, and the MH hotline number. Additional nursing support is needed during this true perioperative emergency.
🌟Emergency Care of the Patient with Malignant Hyperthermia
• Stop all inhalation anesthetic agents and succinylcholine.
• If an endotracheal tube (ET) is not already in place, intubate immediately.
• Ventilate the patient with 100% oxygen, using the highest possible flow rate.
• Administer dantrolene sodium (Dantrium) IV at a dose of 2 to 3 mg/kg.
• Administer 100% oxygen.
• If possible, terminate surgery. If termination is not possible, continue surgery using anesthetic agents that do not trigger malignant hyperthermia (MH).
• Assess arterial blood gases (ABGs) and serum chemistries for metabolic acidosis and hyperkalemia.
• If metabolic acidosis is evident by ABG analysis, administer sodium bicarbonate IV.
• If hyperkalemia is present, administer 10 units of regular insulin in 50 mL of 50% dextrose IV.
• Use active cooling techniques:•Administer iced saline (0.9% NaCl) IV at a rate of 15 mL/kg every 15 minutes as needed.
•Apply a cooling blanket over the torso.
•Pack bags of ice around the patient's axillae, groin, neck, and head.
•Lavage the stomach, bladder, rectum, and open body cavities with sterile iced normal saline.
• Insert a nasogastric tube and a rectal tube.
• Monitor core body temperature to assess effectiveness of interventions and to avoid hypothermia.
• Monitor cardiac rhythm by electrocardiography (ECG) to assess for dysrhythmias.
• Insert a Foley catheter to monitor urine output.
• Treat any dysrhythmias that do not resolve on correction of hyperthermia and hyperkalemia with antidysrhythmic agents other than calcium channel blockers.
• Administer IV fluids at a rate and volume sufficient to maintain urine output above 2 mL/kg/hr.
• Monitor urine for presence of blood or myoglobin.
• If urine output falls below 2 mL/kg/hr, consider using osmotic or loop diuretics, depending on the patient's cardiac and kidney status.
• Contact the Malignant Hyperthermia Association of the United States (MHAUS) hotline for more information regarding treatment: (800) 644-9737.
• Transfer the patient to the intensive care unit (ICU) when stable.
• Continue to monitor the patient's temperature, ECG, ABGs, electrolytes, creatine kinase, coagulation studies, and serum and urine myoglobin levels until they have remained normal for 24 hours.
• Instruct the patient and family about testing for MH risk.
• Refer the patient and family to the Malignant Hyperthermia Association of the United States at (800) 986-4287 or www.mhaus.org.
• Report the incident to the North American Malignant Hyperthermia Registry at the University of Pittsburgh: (412) 692-5464.
MH is a genetic disorder
-with an autosomal dominant pattern of inheritance. The patient with a genetic predisposition for MH is at risk for this complication from halothane, enflurane, isoflurane, desflurane, sevoflurane, and succinylcholine. This rare syndrome is most common in young adults. Males are affected more often than females (despite the autosomal dominant pattern of inheritance) because of gender differences in muscle mass. Once a patient or family history of MH is known, family members can have a muscle biopsy to determine whether they are at risk. The muscle biopsy tested with the caffeine halothane contracture test (CHCT) is still considered the "gold standard" for MH testing even though this disorder is inherited. Currently, no definitive genetic test identifies all people at risk for MH. When a patient is determined to be at risk for MH, he or she can still have anesthesia and surgery; however, more precautions are needed and different anesthetic agents are used.
Overdose of anesthetic
-can occur if the patient's metabolism and drug elimination are slower than expected. This is more likely to occur in patients who are older or who have liver or kidney problems.
-Death during surgery is more often related to pre-existing health problems than to anesthetic overdose.
-occurs as an anesthesia-induced complication. Failure to exchange gases adequately can lead to cardiac arrest, permanent brain damage, and death. Monitoring standards include the use of an end-tidal carbon dioxide monitor to confirm carbon dioxide in the patient's expired gas and a breathing system disconnect monitor to detect any break in the breathing circuit equipment.
-can include many problems (e.g., broken or injured teeth and caps, swollen lip, vocal cord trauma). Intubation may be difficult because of anatomic variance or disease presence (e.g., small oral cavity, tight jaw joint, presence of tumor). Improper neck extension during intubation also may cause injury. The surgeon should be in the operating room (OR) during the intubation process in case a tracheostomy is needed when the endotracheal tube (ET) is placed. ET placement causes tracheal irritation and edema. Often the patient has a sore throat after surgery.
Local or regional anesthesia
-briefly disrupts sensory nerve impulse transmission from a specific body area or region. Motor function may or may not be affected. The patient remains conscious and can follow instructions. Because the gag and cough reflexes remain intact, the risk for aspiration is low.
-delivered topically (applied to the skin or mucous membranes of the area to be anesthetized) and by local infiltration (injected directly into the tissue around an incision, wound, or lesion). Sometimes when the term local is used, it means any form of anesthesia that is not general anesthesia.
-type of local anesthesia that blocks multiple peripheral nerves in a specific body region. It may be used when general anesthesia cannot be used because of medical problems, when the patient has had adverse reactions to general anesthesia, when the patient has a preference and a choice is possible, and when pain management after surgery is enhanced by regional anesthesia. If the patient has eaten and the surgery is an emergency, it may be possible to perform surgery with the patient under regional anesthesia (depending on the procedure) to decrease the risk for aspiration.
- A series of injections around the operative field
-Most commonly used for chest procedures, hernia repair, dental surgery, and some plastic surgeries
-Injection of the local anesthetic agent into or around one nerve or group of nerves in the involved area
-Most commonly used for limb surgery or to relieve chronic pain
-Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space (see Fig. 17-9)
-Most commonly used for lower abdominal, pelvic, hip, and knee surgery
-Injection of an agent into the epidural space (see Fig. 17-9)
-Most commonly used for anorectal, vaginal, perineal, hip, and lower extremity surgeries
The nurse's role in the delivery of regional anesthesia consists of:
•Assisting the anesthesia provider
•Observing for breaks in sterile technique
•Providing emotional support for the patient
•Staying with the patient
•Offering information and reassurance
•Positioning the patient comfortably and safely
Complications of Local or Regional Anesthesia
-related to patient sensitivity to the anesthetic agent (anaphylaxis), incorrect delivery technique, systemic absorption, and overdose. The nurse observes for central nervous system (CNS) stimulation followed by CNS and cardiac depression, which are signs of a systemic toxic reaction. The nurse also assesses for restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea, vomiting, tremors, seizures, and increased pulse, respirations, and blood pressure. Interventions include establishing an open airway, giving oxygen, and notifying the surgeon. Usually a fast-acting barbiturate is needed for treatment. If the toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.
may occur as a rare complication of spinal anesthesia. Epinephrine is given to prevent cardiac arrest in patients who develop sudden, unexplained bradycardia.
include edema and inflammation as early problems. Abscess formation, tissue necrosis, and/or gangrene may occur later. Abscesses result from contamination during injection of the agent. Necrosis and gangrene are rare but may occur as a result of prolonged blood vessel constriction in the injected area.
Moderate sedation, formerly called conscious sedation
is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness but allow the patient to maintain a patent airway and to respond to verbal commands. The amnesia action is short, and the patient usually has a rapid return to ADLs.
-is used for endoscopy, cardiac catheterization, closed fracture reduction, cardioversion, and other special but short procedures.
commonly used drugs for Moderate sedation
(Valium, Vivol , Novo-Dipam ), midazolam (Versed), fentanyl (Sublimaze), alfentanil (Alfenta), propofol (Diprivan), and morphine sulfate
Selection of patients for moderate sedation
-based on specific criteria. The physician determines whether the patient is a candidate. In most states, a credentialed registered nurse may deliver moderate sedation under physician supervision and within the state-defined scope of nursing practice. Credentialing includes advanced training in IV drug delivery, airway management, and advanced cardiac life support (ACLS).
The nurse monitors... for moderate sedation
The airway, level of consciousness, capnography (measure of carbon dioxide level), oxygen saturation, ECG status, and vital signs are monitored every 15 to 30 minutes until the patient is awake and oriented and vital signs have returned to baseline levels
Evaluation of consciousness for recovery from moderate sedation
performed using the criteria of the Ramsay Sedation Scale (RSS) (Table 17-5). This scale lists specific patient responses or behaviors to a continuum of environmental stimulation; the measures in this scale demonstrate degree of arousal from sedation without hurting the patient or unduly startling him or her.
The patient receiving IV moderate sedation can be discharged ...
to go home with a responsible adult if capnography indicates adequate gas exchange and arousal from sedation is at an RSS 2 level. If the patient returns to the general medical-surgical nursing unit, the unit staff nurses continue monitoring. The patient is expected to be sleepy but arousable for several hours after the procedure. Oral intake is not permitted
Administration of spinal and epidural anesthesia
A, Spinal or epidural anesthesia is administered by inserting a spinal needle between the second and third or the third and fourth lumbar vertebrae (L2-3 or L3-4). The patient is placed in the flexed lateral (fetal) position (shown here) or seated on the edge of the operating bed with the back arched and the chin tucked to the chest. B, Spinal anesthesia (viewed from the side). A large needle is inserted to the surface of the dura mater, and a second, smaller needle is passed through the first to penetrate the dura mater and arachnoid mater. An anesthetic is injected, sometimes through an indwelling catheter, directly into the cerebrospinal fluid in the subarachnoid space. C, Epidural anesthesia (viewed from the side). The needle is inserted to the surface of the dura mater, and the anesthetic is injected, usually through an indwelling catheter, into the epidural space.
RAMSAY SEDATION SCALE FOR ASSESSING POST-SEDATION CONSCIOUSNESS
Patient is anxious and agitated or restless, or both.
Patient is co-operative, oriented, and tranquil (calm, not agitated).
Patient responds quickly, but only to commands.
Patient exhibits brisk response to light tapping on the forehead above the nose between the eyebrows (glabella) or a loud noise (auditory stimulus) or responds slowly to commands.
Patient exhibits a sluggish response to light glabellar tapping or loud auditory stimulus.
Patient exhibits no response to light glabellar tapping or loud auditory stimulus, which indicates he or she is not conscious. The RSS must be reapplied at intervals until full consciousness is achieved.
correct identification of the patient
-is the responsibility of every member of the health care team.
The Joint Commission's NPSGs require
-that you verify the patient's identity with two types of identifiers (name, medical record number, telephone number, or other person-specific identifier). Ask the patient to tell you his or her name.
Validation for surgery
-When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before and at the time of surgery. The Joint Commission now recommends that the patient and the professional who knows the most about the patient (usually the surgeon performing the surgery) mark the surgical site
If the patient's description of the surgical site is different from that listed on the informed consent
form a time-out with the patient, yourself, and the surgeon to ascertain and mark the correct site.
Although the denture plate could become loose and obstruct the airway during surgery
the anesthesia provider may request that dentures be left in place to ensure a snug fit of the bag-mask. In some facilities, patients may wear eyeglasses and hearing aids until after anesthesia induction.
Advance Directives and Do-Not-Resuscitate Orders
-Association of periOperative Registered Nurses regarding the care of patients with DNR orders states that automatically suspending a DNR or allow-natural-death order during surgery undermines a patient's right to self-determination
-Advance directives are to be honored in the surgical environment regardless of the situation.
-to iodine products or shellfish indicate a risk for a reaction to the agents used to clean the surgical area. Latex allergies are assessed with all patients. Latex-induced anaphylaxis accounts for about 10% of the anaphylactic reactions that occur during surgery (see Chapters 19 and 22). Latex-free equipment and supplies are used when there is a latex allergy.
Laboratory and Diagnostic Test Results
- are usually obtained within 24 to 48 hours before surgery for hospitalized patients and within 4 weeks for ambulatory surgery patients. The nurse reports all abnormal findings or results to the surgeon and anesthesia provider. Laboratory values greater than or less than the normal range are potentially life threatening for the patient having surgery (see Chapter 16). For example, if the hemoglobin level is less than 10 g/dL, oxygen transport capacity is reduced, affecting the amount and type of anesthesia used as well as the impact of blood loss during surgery.
Intraoperative Autologous Blood Salvage and Transfusion
• Be aware of the cell-processing method to be used.
• Make sure that collection containers are labeled for the patient.
• Assist with sterile setup as necessary.
• Assist with processing and reinfusing procedures as needed.
• Document the transfusion process.
• Monitor the patient's vital signs during the transfusion procedure.
Medical History and Physical Examination Findings
-Older patients and those who are thin or overweight are at greater risk for skin injury. Assessing mental status is important because confused patients and those who are unable to either follow instructions or communicate may not be able to tell you when a problem exists. Patients who have sensory impairment of any type are at increased risk for injury. Specific drugs, such as long-term steroid use (which increases capillary fragility and thins the skin) or fluoroquinolone antibiotics (which increase the risk for tendon rupture), as well as limitations of range or motion, require modification during positioning and threaten patient safety.
the nurse may insert an IV catheter and perform a surgical skin preparation.
After completing the medical record review
Intraoperative Nursing Interventions
• Allow patients to retain eyeglasses, dentures, and hearing aids until anesthesia has begun.
• Use a small pillow under the patient's head if his or her head and neck are normally bent slightly forward.
• Lift patients into position to prevent shearing forces on fragile skin.
• Position arthritic and artificial joints carefully to prevent postoperative pain and discomfort from strain on those joints.
• Pad bony prominences to prevent pressure sores.
• Provide extra padding for those patients with decreased peripheral circulation.
• Use warming devices to prevent hypothermia.
• Cover the patient's head and feet.
• Warm IV and irrigation fluids as indicated by agency policy and manufacturer's recommendations.
• Follow strict aseptic technique.
• Carefully monitor intake and output, including blood loss.
🌟Once the patient has been moved into the holding area or the OR
do not leave him or her alone.
Priority problems for patients during surgery are:
1 Potential for injury related to improper positioning
2 Potential for infection related to invasive procedures
3 Potential for hypoventilation related to anesthesia, pain, reduced respiratory effort
The patient is expected to be free of injury as indicated by:
•Adequate capillary refill and peripheral pulses in all extremities
•Peripheral sensation and motor function after surgery at the same level as before surgery
•Absence of skin redness or open skin areas
•Absence of bruising
after transfer to the operating bed
The patient is usually in a supine position. Anesthesia may be initiated with the patient supine, and he or she may then be repositioned for surgery
Factors influencing the timing of repositioning include:
•The surgical site
•The age and size of the patient
•The anesthetic delivery technique
•Pain on movement (conscious patient)
Factors influencing the actual position include:
•The specific procedure being performed
•The surgeon's request
•The patient's age, size, and weight
•Any pulmonary, skeletal, or muscular limitations, such as arthritis, joint replacements, emphysema, or implanted devices
positions are most often used for surgery
The dorsal recumbent (supine), prone, lithotomy, and lateral positions
Proper positioning is ensured by assessing for:
•Interference with circulation and breathing
•Protection of skeletal and neuromuscular structures
•Optimal exposure of the operative site and IV line
•Adequate access to the patient for the anesthesia provider
•The patient's comfort and safety
•Preservation of the patient's dignity
The nurse ensures proper padding and position changes at regular intervals. He or she continually assesses adequacy of circulation by checking pulses and capillary refill below pressure points. Throughout the surgery, the nurse prevents obstruction of circulation, respiration, or nerve conduction caused by tight straps, poorly placed pads and pillows, or the position of the bed.
Prevention of Brachial Plexus Complications (Paralysis, Loss of Sensation in Arm and Shoulder)
• Pad the elbow if tucked at the side.
• Avoid excessive abduction.
• Secure the arm firmly on a padded armboard, positioned at shoulder level, and extended less than 90 degrees.
Prevention of Radial Nerve Complications (Wrist Drop)
• Support the wrist with padding.
• Be careful not to overtighten wrist straps.
Prevention of Medial or Ulnar Nerve Complications (Hand Weakness, Claw Hand)
• Place the safety strap above or below the nerve locations.
Prevention of Peroneal Nerve Complications (Foot Drop)
• Pad knees and ankles.
• Maintain minimal external rotation of the hips.
• Support the lower extremities.
• Be careful not to overtighten leg straps.
Prevention of Tibial Nerve Complications (Loss of Sensation on the Plantar Surface of the Foot)
• Place the safety strap above the ankle.
• Do not place equipment on lower extremities.
• Urge OR personnel to avoid leaning on the patient's lower extremities.
Prevention of Joint Complications (Stiffness, Pain, Inflammation, Limited Motion)
• Place a pillow or foam padding under bony prominences.
• Maintain the patient's extremities in good anatomical alignment.
• Slightly flex joints and support with pillows, trochanter rolls, or pads.
The patient is expected to have an uninfected surgical wound or wounds. Indicators include:
•Wound edges are closed and not excessively red or swollen
•Wound is free from purulent drainage
•White blood cell counts remain at expected levels after surgery
•Patient is afebrile
Surgical wound infections
-interfere with the patient's recovery, delay wound healing, contribute to rising health care costs, and are a major source of nosocomial infections.
-surgical site infections as occurring 30 days post-surgery and up to 1 year for transplant surgery
Assess the risk for infection
including identifying patients with pre-existing health problems such as diabetes mellitus, immune deficiency, obesity, and kidney disease. The nurse performs the prescribed skin preparation, protects the patient's exposure to cross-contamination, keeps traffic to a minimum, and administers prescribed antimicrobial prophylaxis.
When a wound is already infected
or is at high risk for infection, antibiotics may be used directly in the wound by irrigation or by placing the drug directly into the surgical site before wound closure.
Skin and tissue closures include sutures, staples, and special tape. Fig. 17-11 shows commonly used wound closures. They are used to:
•Hold wound edges in place until wound healing is complete
•Occlude blood vessels, preventing hemorrhage and fluid loss
•Prevent wound contamination
are digested over time by body enzymes
become encapsulated in the tissue during the healing process and remain in the tissue unless they are removed. Body enzymes do not affect nonabsorbable sutures.
Retention (stay) sutures
may be used in addition to standard sutures for patients at high risk for impaired wound healing (those having major abdominal surgery, obese patients, patients with diabetes, and those taking steroids).
After the incision is closed
the surgeon may inject a local anesthetic or instill an antibiotic into the wound. A gauze or spray dressing may be applied to protect the incision from contamination. A variety of dressings may also be used to absorb drainage and support the incision. A pressure dressing may be applied to prevent bleeding. One or more drains (see Chapter 18) may be inserted to remove secretions and fluids from within tissues around the surgical area. These secretions, if not drained, slow healing and promote bacterial growth, which could result in wound infection.
The patient is expected to be free of damaging events related to hypoventilation as indicated by:
•Maintenance of SaO2, PaO2, and blood pH within normal limits
•Vital signs within normal limits
•Return to presurgical level of cognitive function
The nurse, surgeon, and anesthesia provider monitor the patient according to official standards
include continuous monitoring of breathing, circulation, and cardiac rhythms; blood pressure and heart rate recordings every 5 minutes; and the continuous presence of an anesthesia provider during the case.
The nurse evaluates the care of the patient during surgery based on the identified priority patient problems. The expected outcomes are that the patient:
•Is safely anesthetized without complications
•Does not experience any injury related to surgical positioning or equipment
•Is free of skin or tissue contamination during surgery
•Is free of skin tears, bruises, redness, abrasion, or maceration over pressure points and elsewhere
•Maintains normal body temperature
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