3.2 Intraoperative Care Flashcards
1
Q
Intra-Operative Care
A
- Begins when patient is transferred onto the OR bed and ends with admission to PACU
- Surgery is done at hospitals, ambulatory care centers, outpatient surgical centers, physicians offices.
2
Q
Open Surgery
A
- Incisions large enough to allow surgeon to see areas necessary for the surgery.
3
Q
Minimally Invasive Surgery (MIS)
A
- This and robotic surgery are now common practice
- MIS is preferred method
4
Q
INTRAOPERATIVE AREAS
A
5
Q
Unrestricted
A
- Street clothes allowed (clean scrubs for nurses)
- Holding area for patient, locker room, nursing station, family visitation
- IV’s are often started here
- Pre-Op medications are given
- Assessment of pre-op data and confirmations
6
Q
Semi-Restricted
A
- Only authorized personnel are permitted
- Scrub clothes and Caps are required
7
Q
Restricted
A
- Scrub Sink Area
- Operating Room
- Infection control is a priority here
- Scrub clothes, shoe covers, caps, masks are all required
- Filters to control airflow ventilation systems
- Positive air pressure to prevent air from entering the OR
- Aseptic Practice
- Temperature is 68-73 degrees F (20-24C) which is unfavorable for bacteria growth.
8
Q
Members of Surgical Team
A
Patient Anesthesiologist (physician) or CRNA (nurse anesthesiologist) Surgeon Certified Surgical Technologists Nurses
9
Q
Perioperative Nurse
A
- Communication with patient and inpatient unit nurses
- Prepares OR team for patient
- Patient Advocate
- Patient Education
- Documentation Care
10
Q
Circulating Nurse
A
- Leadership
- Manages OR functions, ring equipment, supplies to sterile area, delivery of blood and tissue samples to the lab, surgical safety checklist
11
Q
Scrub Nurse
A
- Manages OR functions within sterile field
12
Q
Registered Nurse First Assistant (RNFA)
A
- Requires formal education
- Collaborates with surgeon and handles tissue, uses instruments, manages homeostasis, does suturing.
13
Q
Surgical Technician
A
- May be filled by LPN, Tech, or RN
- Passes instruments to the surgeon
14
Q
Certified RN Anesthesiologist (CRNA)
A
- Masters Degree
- National certification
- Administers anesthesia and intubates patient
- Monitor patient continuously throughout surgery
15
Q
“Time Out” Second Time
A
- Done in the OR
- Verify patient ID, informed consent, health history, diagnostic tests, allergies, surgical site
16
Q
Safety Measures of OR
A
- Grounding of equipment (fire safety)
- Proper patient positioning
- Restraints
- Do not leave sedated patient unattended
- Blood type verification
- Blood type verification
17
Q
Protection from Infection
A
- First line of defense is environmental controls
18
Q
Surgical Asepsis
A
- At least 1 foot away from sterile field must be maintained
- When sterile area is breached it is contaminated
- Sterile field is constantly monitored
- Items of doubtful sterility are unsterile
- Sterile field prepared as close to surgery time as possible
- All contact with surgical wounds must be sterile
- Edges of sterile packages are contaminated once opened
- Do not reach across sterile field
- Sleeves from 2 inches above elbow to cuff are sterile
- Hair and skin must be covered with proper attire
- Bacteria can travel through moist fabrics
- Movement of surgical team are from sterile to sterile or unsterile to unsterile only.
19
Q
Hyperoxia
A
- Administration of high levels of oxygen
- Not recommended to reduce surgical site infections
20
Q
NURSING MANGEMENT DURING SURGERY
A
21
Q
Positioning of Patient
A
- Done after anesthesia
- Provide correct position to avoid pressure injuries
- Padding and grounding of patient are important
- Most important is comfort, operation field is exposed, position does not obstruct breathing/vascular supply/nerves.
- Extra precautions for thin/obese, physical deformities.
- Light restraints before induction of anesthesia
22
Q
Preparing Surgical Site
A
- Purpose is to reduce organisms that may migrate into wound
- Scrubbing/cleaning of skin around surgical site with antimicrobials
- Clipping hair that may be in site range
- Liberal areas are cleaned then draped
23
Q
Additional Safety Concerns
A
- Use of lasers increase fire risk
- Laser generated airborne contaminants (LGAC) such as dust, metallic fumes, chemical fumes, aerosols
- Appropriate use of respirators, eye protection, gloves during laser procedures is essential.
24
Q
Older Adults
A
- Higher risk for anesthesia complications
- This is due to cardiovascular and pulmonary changes, decreased tissue elasticity, reduced lean body mass, decreased liver metabolism of anesthesia, decreased kidney function, impaired thermoregulation
25
Q
Anesthesia
A
- Definition is loss of feeling or sensation
- In perioperative care it is defined as state of regulated, temporary loss of sensation or awareness for medical purposes
- Can include paralysis/muscle relaxation, unconsciousness, amnesia and analgesia.
26
Q
General Anesthesia
A
- Unconsciousness, analgesia, amnesia, skeletal muscle relaxation, loss of reflex, loss of sensation, elimination of autonomic and sympathetic nervous system.
- Usually used in combination of inhaled drugs such as Isoflurane and parenteral medications such as propofol.
27
Q
Regional Anesthesia
A
- Loss of sensation to a region of the body without loss of consciousness such as epidural or a peripheral nerve block.
28
Q
Monitored Anesthesia Care (MAC)
A
- Similar to general anesthesia but used for therapeutic and diagnostic procedures. (Colonoscopy)
29
Q
Neuromuscular Blockers
A
- Used for paralysis only, or during mechanical ventilation
30
Q
Local Anesthetics
A
- Blockage of a particular sensory transmission to CNS.
- Used for minor surgeries in conscious state
31
Q
Moderate Sedation
A
- Depresses LOC
- Patient can follow commands and protective reflexes remain intact
- Used to reduce pain and anxiety during medical procedure
32
Q
Three phases of General Anesthesia
A
Induction - Includes Stage 1 and 2
Maintenance - Includes Stage 3, 4 and 5
Emergence - Passive process where there is a gradual return to consciousness after administration has ended.
33
Q
4 STAGES OF GENERAL ANESTHESIA
A
34
Q
Stage 1 - Analgesia
A
- Decreases pain transmission
- Conscious and able to converse
35
Q
Stage 2 - Excitement
A
- Systolic BP increase
- Excitation and restlessness
- Possible decreased respiratory rate
- Delirium
- Usually overcome with sedation
36
Q
Stage 3 - Surgical Anesthesia
A
- Regular respirations, beginning of muscle relaxation (light anesthesia)
- Spontaneous respiration ceases (loss of reflex)
- Deep anesthesia (shallow breathing, may require ventilation)
- Breathing may stop entirely
37
Q
Stage 4 - Overdose/Medullary Depression
A
- Respiratory and vasomotor centers are depressed
- Respirations have ceased
- Coma and death will follow without rapid intervention and support
38
Q
Inhaled General Anesthesia
A
- Isoflurane, Sevoflurane, Desflurane (fluranes) are Halogenated Ethers
- Halothane is a Halogenated Hydrocarbon
- Nitrous Oxide
39
Q
Intravenous General Anesthesia
A
- Propofol (Diprivan)
- Fentanyl
- Midazolam (Versed)
40
Q
Inhaled Anesthetics
A
- Ideally produces unconsciousness, muscle relaxation, and amnesia
- Induction and Emergence are brief
- Depth is easily adjusted
- Adverse events minimal
- Large margin of safety
41
Q
Pharmacokinetics Inhaled Anesthetics
A
- Administered through mask, endotracheal tube, laryngeal mask, tracheostomy.
- Enters body through alveoli
- Distribution to CNS is determined by regional blood flow
- Minimally metabolized by liver
- Elimination is through the lungs
42
Q
Adverse Effects Inhaled Anesthetics
A
- Respiratory/Cardiac Depression
- Sensitization of heart to catecholamines, malignant hyperthermia, aspiration of gastric content, hepatotoxicity, toxicity to operating room personnel.
43
Q
Interactions of Inhaled Anesthetics
A
- CNS depressants/stimulants (influence amount required)
- Opioids (lessen amount required)
44
Q
Balanced Anesthesia
A
- Combination of drugs to accomplish the job needed
- This allows lower dose of inhaled anesthetics (safer)
INCLUDES - Short acting barbiturates, neuromuscular blocking agents (muscle relaxation), opioids in addition to anesthetics.
45
Q
Isoflurane
A
- Inhaled Anesthetic
- Used to induce and maintain anesthesia
- Provides sedation and analgesia (reaches surgical anesthesia in 7-10 minutes)
- Administered with nitrous oxide
- Absorbed through lungs and other tissue
CONTRAINDICATIONS - Hypersensitivity, history of malignant hyperthermia, increased intracranial pressure (isoflurane increases cerebral blood flow), pregnancy category C
46
Q
Halothane
A
- Similar to isoflurane but is not a good muscle relaxant
- Causes myocardial depression and drop in BP
- Can cause decrease in cardiac output because of drop in HR from vagal tone (significant)
- Decreased cardiac contractility decreasing cardiac output by 20-50%
- Prolongs QT interval and sensitizes myocardium to catecholamines.
- Great risk for dysrhythmias and cannot be used with epinephrine
47
Q
Nitrous Oxide
A
- Weak anesthetic but powerful analgesic
- Used in combination with other inhaled anesthetics to allow lower dose
- Excreted in respiratory tract
- No serious adverse effects at therapeutic dose
- Pregnancy category C can cause fetal death, growth retardation, skeletal deformities.
48
Q
Adjuncts to Inhalation Anesthesia
A
- Preanesthetic Medications to reduce anxiety, induce amnesia, relieve pre/post operative pain
- Benzodiazepines, opioids, clonidine, alpha 2 adrenergic agonist, anticholinergic drugs.
49
Q
Propofol (Diprivan)
A
Parenteral anesthetic (induction agent)
- Nonbarbiturate Sedative-Hypnotic
- Part of balanced general anesthesia to induce and maintain anesthesia
- Used to sedate patients undergoing procedures
- Rapid loss of consciousness after IV administration
- Administered continuous infusion because it is short lived
- Unconsciousness lasts 3-5 minutes
- <50mcg/kg/min = sedation
- > 50mcg/kg/min = anesthesia
- RN’s can administer for sedation but not anesthesia
- Adverse effects - involuntary muscle movement, transient twitching, tremor, apnea, anaphylaxis, green urine with high dose.
- RESPIRATORY SUPPORT SHOULD BE IMMEDIATELY AVAILABLE
50
Q
Ketamine (Kelalar)
A
- Dissociative anesthetic that has analgesic properties
- Used during induction and maintenance
- Feels detached from environment before Loss of Consciousness
- Sedation, immobility, analgesia, amnesia
- DOES NOT AFFECT AIRWAY REFLEXES OR CIRCULATORY SYSTEM
- Adverse effects - Increased BP and Increased ICP
- Contraindicated in head injury/cerebral edema, brain tumor, glaucoma
- ## Cautiously in coronary artery disease, thyroid disease, and liver disease
51
Q
Moderate Sedation/Analgesia
A
- Mild depression of consciousness
- Desired effect is level of sedation where patient is able to tolerate diagnostic, therapeutic, and invasive procedures through relief of anxiety and pain.
52
Q
Local Anesthesia
A
- Loss of sensation in confined area
- No loss of consciousness
- Blocks sodium channels, which blocks conduction along axons only in neurons near site of administration.
- Suppresses pain without nervous system depression.
- Can be amides or esters.
53
Q
Amides
A
- Lidocaine and bupivacaine
- Intermediate or long-acting
- Lidocaine can be extended with epinephrine
- Metabolized in liver and safer than esters
- Used when patients are allergic to esters
54
Q
Esters
A
- Novocain, procaine, benzocaine (short acting)
- Tetracaine (long acting)
- Metabolized in serum by esterases
- Causes high risk of allergic reactions and systemic toxicity
55
Q
Local Anesthetic Administration
A
- Topical application, local infiltration, regional injection
56
Q
Regional Injections
A
- Peripheral Nerve Blocks
- IV Regional Blocks
- Spinal Anesthesia
- Epidural Anesthesia
57
Q
Lidocaine
A
- Nerve blocks, dental procedures, eye surgery
- Epinephrine prolongs the anesthesia, reduces risk of toxicity due to slower absorption, decreases excessive bleeding.
- Epinephrine and Lidocaine should NEVER BE USED in hands and feet due to risk of ischemia.
- Contraindicated in patients allergic to amides and sulfites.
- Do not apply topically to traumatized tissue
- Comes in cream, ointment, jelly, solution, aerosol and patches.
58
Q
Adverse Effects of Surgery and Anesthesia
A
- Allergic reactions, drug toxicity, drug reactions
- Cardiac dysrhythmias from change in oxygenation, airway complications, or medications.
- CNS changes from medication or hypoxia
- Over sedation
- Hypotension and thrombosis.
59
Q
Catastrophic Events
A
- Anaphylactic Reactions
(Hypotension, Tachycardia, Bronchospasm) - Negative Pressure Pulmonary Edema (NPPE) - Complication of anesthesia that results in laryngospasm during extubation
- Latex Allergy
- Malignant Hyperthermia
- Fire in OR
60
Q
Malignant Hyperthermia (MH)
A
- Rapid rise in core temperature (105 or higher)
- Rare metabolic disease
- Hyperthermia with rigidity of skeletal muscles
- Occurs during general anesthesia with (Succinylcholine)
- Tachycardia, tachypnea, hypercarbia, ventricular arrhythmias
- Obtain careful family history, genetic disorder
