Intra Operative Post operative Nursing Intraoperative Care Objectives

Intra Operative & Post operative Nursing

Intraoperative Care

Objectives: At the end of this lab, the student must be able to: Intra operative nursing care. Discuss Duties of the Nurses in OR: Reception Nurse Anesthetic Nurse Circulating Nurse Scrub Nurse Discuss immediate and later postoperative care. Postoperative discomfort pain. Identify the postoperative complications Wound care. Post-operative discharge instructions

• The intraoperative phase begins when the patient is transferred onto the operating room table and ends when he or she is admitted to the postanesthesia care unit (PACU). • In this phase, the scope of nursing activity can include • Providing for the patient’s safety, • Maintaining an aseptic environment • Ensuring proper function of equipment, • Providing the surgeon with specific instruments and supplies for the surgical field, • Completing appropriate documentation.

• In some instances, the nursing activities can encompass • Providing emotional support by holding the patient’s hand during general anesthesia induction, • Assisting in positioning the patient on the operating room table using basic principles of body alignment, • Or acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA).

Intraoperative Phase Maintenance of Safety • 1. Maintains aseptic, controlled environment • 2. Effectively manages human resources, equipment, and supplies for individualized patient care • 3. Transfers patient to operating room bed or table • 4. Positions the patient • Functional alignment • Exposure of surgical site • 5. Applies grounding device to patient • 6. Ensures that the sponge, needle, and instrument counts are correct • 7. Completes intraoperative documentation

Physiologic Monitoring • 1. Calculates effects on patient of excessive fluid loss or gain • 2. Distinguishes normal from abnormal cardiopulmonary data • 3. Reports changes in patient vital signs • 4. Institutes measures to promote normothermia Psychological Support (Before Induction and When Patient Is Conscious) • 1. Provides emotional support to patient • 2. Stands near or touches patient during procedures and induction • 3. Continues to assess patient emotional status

Intraoperative Nursing Roles

1. Identified patient by asking him to say his name and checks and corresponds with his record and reporting list. 2. Reassures patients , creates quiet , calm atmosphere to decrease patient apprehensiveness. 3. Checks the preoperative assessment 4. Confirms that the patient has signed the operating consent. 5. Checks the time of administrative order premedication and any adverse reaction is reported to anesthetist. 6. Uses the check list to complete the preparation for anesthesia and surgery. 7. Transfer patient to the anesthetic room.

• Prepares safe environment for induction of anesthesia. • Checks suction apparatus , gas supply , gas cylinder machine to be well prepared for use. • Checks O 2 supply and emergency tray in position. • Checks and records all drugs required by the anesthetist.

• Arranges for the scrub nurse to see the signed consent. • Prepares inhalation trolley • Assist in the transfer patient to recovery room • Cleans used equipment

1. Managing the nursing care of the patient and coordinating the needs of surgical team members for each procedure, using critical thinking skills. 2. Observes the procedure from a broad perspective and helps team members create. 3. Assess the patient’s condition before, during, and after the procedure.

4. Maintains a safe care environment. 5. Manages equipment use and delegates / directs care provided by OR technicians. 6. Performs the role of scrub nurse when necessary. 7. Is responsible for directing and coordinating all nursing care based on established clinical nursing practices. 8. Continuously evaluates patients outcomes during intra operative phase.

1. Before scrubbing: Assists circulating nurse in preparation of operation theater. 2. After scrubbing: 1. Prepare the sterile instruments. 2. Performs proper draping. 3. Assist surgeons in wearing gowns and gloves. 4. Prepare appropriate needles and sutures. 5. Counts all swabs, sponges, and sterile instruments.

6. Arranges sterile instruments in expected orders for use. 7. Hands instruments to the surgeons and helps to keep an eye on the patients condition. 8. Listens carefully to what the surgeon is saying. 9. Counts instruments before wound closure.

THE REGISTERED NURSE FIRST ASSISTANT • The registered nurse first assistant (RNFA) is another member of the operating room staff. • RNFA practices under the direct supervision of the surgeon. • RNFA responsibilities may include • Handling tissue, • Providing exposure at the operative field, • Suturing, and • Providing hemostasis.

The Surgical Environment The surgical environment is known for its stark appearance and cool temperature. The surgical suite is behind double doors, and access is limited to authorized personnel. External precautions include • Adhering to principles of surgical asepsis; • Strict control of the operating room (OR) environment is required, including traffic pattern restrictions. • Policies governing this environment address such issues as the health of the staff; the cleanliness of the rooms; the sterility of equipment and surfaces; processes for scrubbing, gowning, and gloving; and OR/OT attire.

• OR is situated in a location that is central to all supporting services (eg, pathology, radiology, laboratory). • The OR has special air filtration devices to screen out contaminating particles, dust, and pollutants. • The temperature, humidity, and airflow patterns are controlled (Meeker et al. , 1999). • Electrical hazards, emergency exit clearances, and storage of equipment and anesthetic gases are monitored periodically by official entities • To help decrease microbes, the surgical area is divided into three zones: the • Unrestricted zone, where street clothes are allowed; • Semi-restricted zone, where attire consists of scrub clothes and caps; • Restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. • The surgeons and other surgical team members wear additional sterile clothing and protective devices during the operation.

The Surgical Experience During the surgical procedure, the patient will need sedation, anesthesia, or a combination of these. • SEDATION AND ANESTHESIA • Sedation and anesthesia have four levels: minimal sedation, moderate sedation, deep sedation, and anesthesia. • A surgical procedure may also be performed using anesthetic agents that suspend sensation in parts of the body (local, regional, epidural, or spinal anesthesia). • For the patient, the anesthesia experience consists of • Having an intravenous line inserted, • Receiving a sedating agent prior to induction with an anesthetic agent; • Losing consciousness; • Being intubated, • Then receiving a combination of anesthetic agents.

Minimal Sedation • The minimal sedation level is a drug-induced state during which • the patient can respond normally to verbal commands. Cognitive • function and coordination may be impaired, but ventilatory and • cardiovascular functions are not affected

Moderate Sedation • Moderate sedation is a form of anesthesia that may be produced intravenously. • It is defined as a depressed level of consciousness that does not impair the patient’s ability to maintain a patent airway and to respond appropriately to physical stimulation and verbal commands. • Its goal is a calm, tranquil, amnesic patient who, when sedation is combined with analgesic agents, is relatively painfree during the procedure but able to maintain protective reflexes

• Midazolam (Versed) or diazepam (Valium) is used frequently • Other medications used include analgesic agents (eg, morphine, fentanyl) and reversal agonists, such as naloxone (Narcan). • A nurse who is knowledgeable and skilled in detecting dysrhythmias, administering oxygen, and performing resuscitation must continuously monitor the patient who receives sedation. • The patient receiving this form of anesthesia is never left alone and is closely monitored for respiratory, cardio- vascular, and central nervous system depression using such methods as pulse oximetry, ECG, and frequent measurement of vital signs • (Patterson, 2000 a, b)

Activity • Describe Anaesthesia and its stages • List out the types of Anaesthetic agents • What are the methods of Administration of Anaesthetics

Potential Intraoperative Complications The surgical patient is subject to several risks. Potential intraoperative complications include • Nausea and vomiting, • Anaphylaxis, • Hypoxia, • Hypothermia, • Malignant hyperthermia, and • Disseminated intravascular coagulopathy.

Nausea and vomiting • If gagging occurs, the patient is turned to the side, • The head of the table is lowered, and a basin is provided to collect the vomitus. • Suction is used to remove saliva and vomited gastric contents. • In some cases, the anesthesiologist administers antiemetics preoperatively or intraoperatively to counteract possible aspiration. • If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. • Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia.

Anaphylaxis, • Any time a substance foreign to the patient is introduced, there is the potential for an anaphylactic reaction. • Medications are the most common cause of anaphylaxis, • Intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. • An anaphylactic reaction can occur in response to many medications, latex, or other substances. • The reaction may be immediate or delayed. • Anaphylaxis is a life threatening acute allergic reaction that causes vasodilation, hypotension, and bronchial constriction • Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures (Kassam et al. , 2002; Vargas & Reger, 2000). • These sealants have been implicated in allergic reactions and anaphylaxis.

Hypoxia, • Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia are significant potential problems of general anesthesia. Many factors can contribute to inadequate ventilation. • Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretions or vomitus, and the patient’s position on the operating table can compromise the exchange of gases. • Anatomic variation can make the trachea difficult to visualize and result in the artificial airway being inserted into the esophagus rather than the trachea. • In addition to these dangers, asphyxia caused by foreign bodies in the mouth, spasm of the vocal cords, relaxation of the tongue, or aspiration of vomitus, saliva, or blood can occur. • Since brain damage from hypoxia occurs within minutes, vigilant assessment of the patient’s oxygenation status is a primary function of the anesthesiologist or anesthetist and the circulating nurse. • Peripheral perfusion is checked frequently, and pulse oximetry values are monitored continuously.

Hypothermia, • During anesthesia, • The patient’s temperature may fall. • Glucose metabolism is reduced, • And as a result metabolic acidosis may develop. • This condition is called hypothermia and is indicated by a core body temperature below normal (36. 6°C [98. 0°F] or lower). • Inadvertent hypothermia may occur as a result of • a low temperature in the OR, • infusion of cold fluids, • inhalation of cold gases, • open body wounds or cavities, • decreased muscle activity, • advanced age, or • the pharmaceutical agents used (eg, vasodilators, phenothiazines, general anesthetics).

• Hypothermia may also be intentionally induced in selected surgical procedures (such as cardiac surgeries requiring cardiopulmonary bypass) to reduce the patient’s metabolic rate (Finkelmeier, 2000). • If hypothermia occurs, the goal of intervention is to minimize or reverse the physiologic process. If hypothermia is intentional, the goal is safe return to normal body temperature. • Environmental temperature in the OR can temporarily be set at 25° to 26. 6°C (78° to 80°F). • Intravenous and irrigating fluids are warmed to 37°C (98. 6°F). • Wet gowns and drapes are removed promptly and replaced with dry materials because wet linens promote heat loss. • Whatever methods are used to rewarm the patient, warming must be accomplished gradually, not rapidly. • Conscientious monitoring of core temperature, urinary output, ECG, blood pressure, arterial blood gas levels, and serum electrolyte levels is required.

Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents (Fortunato-Phillips, 2000; Vermette, 1998). Susceptible people include Those with strong and bulky muscles, A history of muscle cramps or muscle weakness and unexplained temperature elevation, and An unexplained death of a family member during surgery that was accompanied by a febrile response. Pathophysiology When nerve impulses stimulate the muscle, calcium is released, allowing contraction to occur. A pumping mechanism returns calcium to the sacs so that the muscle can relax. In malignant hyperthermia, this mechanism is disrupted. Calcium ions are not returned and they accumulate, causing clinical symptoms of hypermetabolism, which in turn increases muscle contraction (rigidity), hyperthermia, and damage to the central nervous system.

Clinical Manifestations • The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. • Tachycardia (heart rate above 150 beats/min) • Sympathetic nervous stimulation leads to ventricular dysrhythmia, • Hypotension, • Decreased cardiac output, • Oliguria, and later, • Cardiac arrest. • With the abnormal transport of calcium, rigidity or tetanus-like movements occur, often in the jaw. • Body temperature can increase 1° to 2°C (2° to 4°F) every 5 minutes (Meeker & Rothrock, 1999). • The temperature can reach or exceed 40°C (104°F) in a very short time (Fortunato-Phillips, 2000).

Medical Management • Recognizing symptoms early and discontinuing anesthesia promptly are imperative. • Goals of treatment are • to decrease metabolism, • reverse metabolic and respiratory acidosis, • correct dysrhythmias, • decrease body temperature, • provide oxygen and nutrition to tissues, and • correct electrolyte imbalance. • Although malignant hyperthermia usually presents about 10 to 20 minutes after induction of anesthesia, it can also occur in the first 24 hours after surgery.

• As soon as the diagnosis is made, anesthesia and surgery are halted and the patient is hyperventilated with 100% oxygen. • Dantrolene sodium, a skeletal muscle relaxant, and sodium bicarbonate are administered immediately (Fortunato Phillips, 2000; Vermette, 1998). • Continued monitoring of all parameters is necessary to evaluate the patient status

Nursing Management • Although malignant hyperthermia is uncommon, the nurse must identify patients at risk, recognize the signs and symptoms, have the appropriate medication and equipment available, and be knowledgeable about the protocol to follow (Fortunato-Phillips, 2000). This information may be lifesaving.

Disseminated intravascular coagulopathy • Disseminated intravascular coagulopathy is a lifethreatening condition characterized by thrombus formation and depletion of select coagulation proteins (Dice, 2000). • The exact cause is unknown, • but predisposing factors include many conditions that may occur with emergency surgery, such as • Massive trauma, • Head injury, • Massive transfusion, • Liver or kidney involvement, • Embolic events, or • Shock.

Postoperative Care

• Immediate post operative period: Initial assessment: • Airway patency • Effectiveness of respiration • Presence of artificial airways • Mechanical ventilation, or supplemental oxygen • Circulatory status, vital signs • Wound condition, including dressings and drains • Fluid balance, including IV fluids, output from catheters and drains and ability to void • Level of consciousness and pain

• Later post operative period: Ongoing assessment: • Respiratory function • General condition • Vital signs • Cardiovascular function • Fluid status • Pain level • Bowel and urinary elimination • Dressings, tubes, drains, and IV lines

Nurse’s roles in the post-operative phase: • Ensures a patent airway • Helps maintain adequate circulation • Prevents or assist with the treatment of shock • Maintains proper position and function of drain tubes and IV infusion • Monitor for potential complications

• Hemorrhage • Shock • Hypoxia • Aspiration

Thank you for your attention