Operative Nursing Flashcards
Time Out/Pause for Cause
- Performed by patient & entire healthcare team (nurse, surgeon, anesthesiologist, resident, tech)
- Confirm pt identity, surgical procedure, surgical site
Time Out Elements
*Correct patient: state full name as printed on ID band + 2nd identifier (dob, SS, telephone, address, photo)
*Correct procedure: pt state
*Correct surgical site: pt state & signed by surgeon/pt
- Other things reported: positioning, medications, etc.
When are time outs done
- Preoperative period
- Entry into surgical suite prior to anesthesia
- Before incision
Informed consent for?
Surgery & anesthesia
- Communication between surgeon and pt
- Legal and ethical requirement
Role of surgeon/anesthesiologist in informed consent
Obtain informed consent
Role of nurse in informed consent
- Double check: clarify info, ensure pt understanding, correct misconceptions
- Emotional: ease concern of pt/family/support person
- Witness to process and sign form
Components of surgical informed consent
- Consent for procedure/anesthesia
- Name of surgeon/anesthesiologist
- Reason surgery/anesthesiology will benefit pt
- Alternative options for surgery/anesthesia
- Consent to administer blood products for surgery
Inability to consent
Cognitive impairment, Deaf/foreign language, Cannot physically sign, Minors, Emergencies
- Durable power of attorney signs eg. guardian
- Hospital interpret, can’t sign – mark an X
- Minors: parent/legal guardian, old enough
- Emergency: verbal consent or two providers sign
Nurse role before surgery for advanced directive
Document existence of AD/Living Will and place a copy of these documents in chart
Nursing management: preoperative history
- *Allergies/sensitivities (latex)
- *Last oral intake
- *Any medical implants or devices
- *Any piercings
- Previous anesthesia + response
- Surgical history, healing history
- Social history: alc, smoking, etc.
- History of mental illness/abuse
- Support systems
- Advanced directives
Preoperative nursing assessment
*Medications assessment: lab analysis or focused physical exam
- Anticoags: heparin, warfarin, lovenox –> bleeding risk
- Glucose metabolism altering meds: insulin, oral hypoglycemic agents, chronic steroid use –> hyperglycemia or hypoglycemia
- Antihypertensives: diuretics, beta blockers, ACE inhibitors –> hypotension in combo w other meds, hypertension without
- *Confirm skin and bowel prep completed
- Vital signs
- Head-to-toe physical exam
- Radiology tests
Nursing management: preoperative interventions
- *IV insertion
- *Ensure removal of jewelry and prosthetics
- Administer any preoperative meds, like anti-anxiety
- Foley catheter (usually done in OR)
- Skin prep (shaving usually done in OR)
- Inform anesthesia and surgical team of implants
- Time-out
Nursing management: preoperative teaching
- Anticipatory guidance (relieve anxiety)
- OR experience
- Recovery
- DVT prophylaxis: SCD, heparin, Ted hose, mobility
- Mobility prior to surgery
- Prevent pneumonia: cough + deep breathing
Sterile team members
Surgeon(s), Surgical assistants, Scrub nurses, Surgical techs, OR techs
Surgeon role
- Leader of surgical team
- May be more than one
Surgical assistant roles (NP, PA)
- Work interdependently w surgeon
- Provide preoperative and postoperative pt care
Scrub nurse, Surgical tech, OR tech roles
- Pass instruments, sponges & other items
- Prepare OR by setting up surgical instruments
- Help surgical team don sterile gowns and gloves
Non-Sterile team members
Anesthesia provider, Circulating RN
Anesthesia provider role (MD or CRNA)
- Constantly aware of surgeon’s actions
- Preoperative evaluation & postoperative care in PACU
Circulating RN role
- Observe procedure, assist surgical team, maintain pt safety
- Assess in preop arena and on admit to OR
- Assist anesthesia in monitor and line placement and pt positioning
- Anticipate supply and medication needs, label specimens
- Count number of needles, instruments, sponges
Surgical scrub procedure
- Prevent surgical infection
- Remove all jewelry and ensure clean nails (no gel or acrylic nails)
- Wash hands thoroughly
- Wash w disposable scrub sponge from clean (hand) to less clean area (arm), 3-5 mins
- Dry w sterile towel provided by scrub nurse
Surgical attire
- All OR roles: scrubs, caps, masks, designated OR shoes or covers
- Sterile field members: all the above + sterile gloves, gown and protective eyewear
Types of intraoperative anesthesia
General (GA), Regional (RA), Monitored-Anesthesia Care (MAC)
General anesthesia
Reversible unconscious states
- Variety of methods: volatile agents (gases), IV agents, muscle relaxants
- Anesthesia w muscle relaxant require endotracheal intubation for ventilation support
Complications of GA
- Hypoxia
- Respiratory/CV dysfunction
- Hypertension/hypotension
- Fluid/electrolyte imbalance
- Residual muscle paralysis
- Malignant hyperthermia
Regional anesthesia
Local anesthetic block or anesthesizes nerve/nerve fiber (pt = awake)
Types of RA:
- Spinal, epidural, caudal, nerve block
- Lidocaine, Bupivacaine, Cocaine
RA adverse effects
- Hypotension
- Spinal headache
- Resp paralysis or nerve damage
- Seizure
Monitored-Anesthesia Care
Anesthesia without unconsciousness
Decreased lvl of consciousness, respond to verbal command, maintain airway
- Benzos, narcotics (Valium/Versed + Fentanyl/Dilaudid)
Intraoperative positioning devices
- OR bed
- Arm board/restraint
- Foam pads, sandbags
- Padding
- Blankets, sheets
- Pillows/towels
- Safety straps
- Bean bags
- Gel type padding
Intraoperative positioning complications
- Pressure injuries
- DVT
- Nerve injury/damage
- Falling
- Diminished lung capacity
High risk pts in intraoperative positioning
- Obese & extremely thin
- Pediatric & geriatric
- Paralyzed
- Diabetes
- Cancer
- Infections
- Trauma
- Prosthetic or arthritic joints
Intraoperative nursing assessment
- Ensure OR consent signed
- Correct pt positioning
- Monitor donning of OR attire
- Ensure supplies available
- Check fluid and instruments for temp
- Confirm flashed instruments are cool
- Fire safety
Intraoperative nursing interventions
- Perform time out
- Perform equipment safety and number check
- Sterile technique
- Assist anesthesia provider during intubation
- Properly ground pt as indicated, keep pt safety belt in place
- Apply support hose and sequential compression devices
- Keep pt warm
- Keep OR doors closed, clear hallway of equipment
Postoperative care timing
- Begin right after surgery
- End at first follow-up postoperative provider visit
- Insurance carriers end postop care at 90 days post-surgery
Phases of post-op care
- Phase I: immediate post-anesthesia period (CV, resp, neuro, ECG, pain/temp)
- Phase II: prepare to transfer to floor/home (void, oral intake, n/v)
- Phase III: observation d/t bed availability (standard postop nursing care)
PACU settings
- Inpt PACU: major to minor surgeries w varying complications
- ICU: critically ill pts require complex monitor
- Outpt PACU: ambulatory surgery centers (plastics, dental, eye)
- Procedure areas: endoscopy, interventional cardiology, IV sedation
Nursing management: PACU postoperative essentials
- Resp status and oxygenation
- Cardiovascular
- Pain management: analgesics, PCA, nonpharm interventions
- Lab monitoring: labs, chest x-ray, EKG
- Fluid and electrolyte replacement
Nursing management: PACU to Med-Surg floor transfer communication
- SBAR
- Fluid status and blood loss
- Description of surgical procedure performed
- IV access, location, peripheral/central, etc.
Types of surgery
- Elective eg. fat removal
- Urgent eg. CA
- Emergency eg. gunshot wound
