Perioperative & Intraoperative Nursing

1. Perioperative & Intraoperative Nursing

2. Perioperative Nursing • Entire operative process which includes: • Preoperative • Before surgery • Intraoperative • During surgery • Postoperative • Following surgery

3. Surgery • The branch of medicine concerned with diseases and trauma requiring operative procedures • Classification of surgical procedures • Admission Status • Ambulatory or outpatient • Same-day admit • Inpatient • Seriousness • Major • Minor

4. Urgency • Elective • Patient’s choice • Urgent • Necessary for patient’s health • Emergency • Must be done immediately to save life or preserve function

5. Purpose • Diagnostic • Confirm diagnosis • Ablation • Excision or removal of diseased body part or removal of a growth or harmful substance • Palliative • Relieves or reduces intensity of disease symptoms • Reconstructive • Restores function or appearance to traumatized or malfunctioning tissue • Transplant • Replaces malfunctioning organs or structures • Constructive • Restores function lost or reduced as result of congenital anomalies

6. Can your patient tolerate surgery? • Age • Young and older patients’ metabolic needs such as temperature changes, cardiovascular shifts, respiratory needs, and renal function, may not respond to physiological changes quickly • Elderly considerations • 86% of elderly have at least one chronic disease • Cardiovascular • Respiratory • Renal and Liver impairment • Short term memory loss affects • Confusion and delirium • Fragile Integumentary system • Thermoregulation issues

7. Physical condition • Surgical effects on Body Systems • Coexisting health problems especially Diabetes • Nutritional factors • "Nitrogen Balance" expresses the balance between anabolism and catabolism • Measured by assessing dietary intake vs. urinary output (as urea)

8. "Positive" nitrogen balance (net storage of nitrogenous compounds): • childhood growth • pregnancy • muscle building • healing  • "Negative" nitrogen balance (net breakdown of stored nitrogenous compounds): • illness • starvation • amino acid deficiency • wounds

9. Socioeconomic and cultural needs • Social • Economic • Religious • Ethnic • Cultural • Education and experience • Life experiences • Educational level

10. Fear • Evidence that a relationship exists between preoperative fear and postoperative behavior • More anesthesia required • More postoperative pain medication needed • Slower speed of recovery • Patient enters an environment in which they have very little control • -needs to feel free to ask questions.

11. Common Fears • Fear of loss of control (anesthesia) • Fear of the unknown (outcome, lack of knowledge) • Fear of anesthesia (waking up) • Fear of pain (pain control) • Fear of death (surgery, anesthesia) • Problem with minor surgery, as well as major • Fear of separation (support group) • Fear of disruption of life patterns (ADLs, work) • Fear of detection of cancer

12. Everyone has an accustomed role, and they are used to doing for themselves. It may be frustrating, painful, embarrassing, etc. to have others’ help.

13. Intra-operative Nursing

14. Errors That Can Occur • Patient misidentification • Incorrect procedure • Foreign bodies left in patient • Patient burns • Falls or positioning errors • Improper handling of specimen • Incorrect drugs or administration

15. Harm secondary to use of defective equipment/instruments • Loss of or damage to patient’s property • Harm secondary to a major break in sterile technique • Exceeding authority or accepted functions

16. There are Hazards! • Physical: noise, ionizing radiation, electricity, injury to body, fire, explosion • Biologic: laser/electrosurgical plume, pathogens , latex sensitivity, sharps injury • Chemical: disinfecting agents, waste anesthetic gas, vapors and fumes • Methyl methacrylate(used in the fields of medicine and dentistry to make prosthetic devices and as a ceramic filler or cement)

17. Fire/explosion can result from: • Source of ignition • Spark from metal hitting metal • Oxygen • Flammable materials • Gas, vapor, liquid (ethyl alcohol) • Electrical • Ionizing radiation • Static electricity • Electrical burns

18. Sterile Environment • Gown • Gloves • Mask • Hair cover • Shoe covers • Movement • Must not compromise the sterile field • Sterile to sterile • Nonsterile to nonsterile • Sterile individuals keep within sterile area Scrub Nurse Circulating Nurse Anesthesiologist

19. A lot of thought goes into the design of operative suites

20. Establishing the Sterile Field • Mask must be applied prior to creation • Sterile items on the sterile field • Established far away from doors and high traffic areas • Kept in constant view

21. Establishing the Sterile Field • Check packaging for integrity • Unfold • First flap away from you • Second flap toward you • Reposition and open third flap • Move to opposite side to open fourth flap

22. Sterile field: In front of you, above the waist and below the shoulder. Carry sterile equipment away from your body.

23. Even the Anesthesiologist is unwelcome in the sterile field! Sterile Work Table Ready to Go

24. Instrument count sheet always included in instrument tray

25. Surgical Ward: Bastion of Fashion Patients must dress appropriately (getting a pediatric patient through induction can be tricky)

26. Shoes need to be covered and grounded

27. If Cleanliness is next to Godliness, this must be Heaven Circulating Nurse Preparing Sterile Gowns and gloves

28. Surgical Hand Scrub Attacking the nails first !

29. 10 Strokes per plane

30. Rinse from hand to elbow

31. Dry with Sterile Towel so Lovingly Laid out by the Circulating Nurse

32. Gowning Sterile

33. How’d he do that??!

34. Waiting for his favorite nurse!

35. Teamwork !

36. The Gas Man!!

37. Anesthesia plays a major part in surgery and pain management. • It’s action interferes with nerve conduction so that the sensation of pain is not perceived by the brain • Two major classes • General • Regional • Local Anesthesia • Conscious Sedation

38. Anesthesia evaluation • Status I - A healthy patient • Status II - Patient with mild-to-moderate systemic disease (e.g., anemia, morbid obesity) • Status III - Patient with severe systemic disease that limits activity but not to the point of incapacitation (eg, healed myocardial infarction, diabetes with vascular complications) • Status IV - Patient with incapacitating systemic disease that is life-threatening (eg, advanced hepatic or renal insufficiency) • Status V - Moribund patient who is not expected to survive (eg, major cerebral trauma, massive pulmonary embolus)

39. Drug Interactions • Antibiotics • Potentiate the action of anesthetic agents • Anticholinergics • Increase the potential for confusion • Anticogulants • Increase the risk for hemorrhaging • Inquire into use of ASA and NSAIDS within 48 hours of surgery because of anti-platelet factor • Anticonvulsants • Long-term use can alter the metabolism of anesthetic agents • Antidepressants • Potentiate lowering of Blood Pressure

40. Antidysrhythmics • Reduce cardiac contractility and impair cardiac conduction during anesthesia • Antihypertensive • Interact with anesthetic agents and cause bradycardia, hypotension and impaired circulation • Corticosteroids • Cause adrenal atrophy and reduce the body’s ability to withstand stress, Need a dosage adjustment prior to surgery • Diuretics • Potentiate electrolyte imbalances after surgery • Herbal Substances • These can interact with anesthesia and cause a variety of adverse effects. These substances need to be stopped at a specific point of time before surgery

41. General Anesthesia • How does it work • Four stages • Stage One: Analgesia -analgesia or a loss of pain sensation -remains conscious and can carry on a conversation. • Stage Two: Excitement -experiences delirium or become violent -elevated blood pressure and respirations -stage is typically bypassed by administering a barbiturate, such as sodium pentothal, before the anesthesia

42. General Anesthesia • Stage Three: Surgical Anesthesia -skeletal muscles -breathing becomes regular -eye movements slow, then stop, and surgery can begin. • Plane 1: Muscle tone decreases; eyelid, gag and swallow reflexes are lost • Plane 2: Muscle tone continues to decrease, pauses occur between respiration and there is a slight change in the pupils • Plane 3: Markedly decreased muscle tone and pupil dilation • Plane 4: Widely dilated pupils and do not respond to light, intercostal muscles are paralyzed resulting in respiratory paralysis; pulse and blood pressure decrease. • Stage Four: Medullary -paralysis, respiratory centers in the medulla oblongata cease to function -death can result if the patient cannot be revived quickly -stage should never be reached

43. Balanced Anesthesia • Characteristics (uses inhalation and injection) • Hypnosis • Amnesia • Muscle relaxation • Relaxation of the neurological reflexes with minimal alteration in physiological function • Effective and controlled level of anesthesia that is safe especially for the elderly clients and those at high risk for pulmonary problems • Goal: Pass clients through stages of anesthesia with minimal side effects

44. Induction of Anesthesia • Generally by IV injection of an ultrashort-acting barbiturates • Theopental sodium • Methohexital sodium • Tends to depress the circulatory and respiratory systems as well as the CNS • Ketamine • Nonbarbituarate • Produces analgesia too • Emergence reaction include confusion, excitement and irrational behavior which can be controlled by IV diazepam (Valium)

45. Etomidate (Amidate) • Nonbarbituate • Does not produce cardiovascular or respiratory depressant effects. • Midazolam HCL (Versed) • Cousin to Valium with amnesia • Needs a Narcotic for analgesia • Propofol (Diprivan) • New IV anesthetic • Amnesiac • Emulsion

46. Inhalation Cricoid Pressure

47. Tools of the Trade Blades and Scopes

48. Risks of Gas Anesthetics • Most are explosive • Nausea and vomiting • Coughing • Renal and liver toxicity

49. Neuromuscular blocking agents • Succinylcholine chloride • Pancuronium bromide (Pavulon) • Relax the jaw and throat muscles immediately following induction so endotraceal tube can be place to maintain a patent airway and facilitate alveolar ventilation during surgery • Used for complete relaxation of the abdominal muscles • May cause circulatory compromise and respiratory muscle paralysis during the surgery

50. Malignant hyperthermia (MH) -inherited myopathy -hypermetabolic state -exposed to some anesthetic agents especially succinylcholine. -reduction in the reuptake of calcium necessary for termination of muscle contraction -muscle contraction is sustained -signs of hypermetabolism. -happens in the operating room -first few hours of recovery from anesthesia.