Week 12 - Intra-op Care Flashcards
how is the physical enviro of the OR designed
- for max infection control in an enviro that makes sense for the work that needs to happen
describe the temp & humidity of the OR: why?
- temp = 20-24*
- humidity = 30-60%
= decrease bacterial growth, keep HCP cool in PPE
what factors help maximize infection control in the OR (6)
- strict personnel rules
- temp & humidity control
- particulate air filters
- ventilation system
- positive pressure system
- ways to make it easier to clean
what is included in strict personnel entrance rules
controls:
- who comes in
- what is worn
what particulate air filter is used to maximize infection control ? why>
- HEPA
- controls and eliminates dust, toxic fumes, genes, microorganisms from the air
why is a positive pressure system in the OR used
- keep air out from the hallway
describe the items in the OR to maximize infection control & make it easier to clean (6)
- space
- stainless steel
- wheels
- plug ins
- lighting
- minimal items of floor
what are 3 main areas of the surgical suite
- unrestricted area
- semi-restricted area
- restricted area
what is included in the unrestricted area? describe clothing in this area
- ex. front desk, locker rooms, pt admin area
- can be in street clothes
what are examples of semi-restricted areas? describe clothing in this area
- ex. corridors between OR rooms, peripheral storage area for sterile supplies
- must wear surgical attire, cover all hair
what are examples of restricted areas? describe attire/rules in this area (5)
- ex. OR rooms, scrub sinks
- surgical attire
- cover all hair
- surgical mask
- no personal belongings
- no food/drink
what is a consideration to reduce cross contam.
- seperate clean & dirty areas –> even when they are leaving the room to be cleaned , cover & contain until they are delivered into decontaminated space
describe the roles of the surgeon on the surgical team member (4)
- determines need for surgical procedure
- determines type of surgery
- responsible for doing the surgery
- post-op mngmt (on unit)
describe the roles of the anasthesiologist on the surgical team (3)
- physician responsible for pts physiologic homeostasis during and shortly after surgery
- ensure anesthesia is maintained throughout the surgery
- ensure pt is stable while in recovery room (RR or PACU)
what are 2 types of nursing in the OR (2)
- circulating nurse
- scrub nurse
describe the sterility of the circulating nurse
- unsterile field
what are the roles of the circulating nurse in the OR (10)
- asssess pt
- position pt
- pt advocate (ensure pt dignity, privacy, confidentiality)
- ensure OR is running well
- ensure adequate supplies
- instigate surgical time outs (if something isnt going well, pause & refocus team)
- assist scrub nurse to count sponges and instruments
- communicat w “outside” –> phone calls, pages
- document & give reports
- greet pt on arrival to postop area
what are roles of the scrub nurse in the OR (4)
- hands on
- passes instruments to surgeon
- advocate for aseptic technique
- ensure there is efficient setup
describe the sterility of the scrub nurse in the OR
- sterile field
what are the principle of aseptic technique (6)
- hand washing before entering OR w surgical scrub
- gowning and gloves put on once in OR (helped by circulating nurse)
- once sterile, cannot touch anything non-sterile
- must keep hands above waist
- cannot reach over any non-sterile field
- note breaches in sterility
what is anesthesia
- an artifically induced state of partial/total loss of sensation with/without consciousness
what determines the type of anesthetic to be given (4)
- length of procedure
- invasivness of procedure
- past health history
- pt/surgeon/anesthetist preference
what are 3 classifications of anesthetics
- general anasthesia
- regional/local anesthesia
- procedural sedation (conscious sedation)
what are differences between the types of anesthesias (3)
- can the pt feel
- can the pt remember
- can pt protect their airway
what effects does general anasthesia have on the CNS (6)
- loss of consciousness
- loss of sensation
- loss of reflexes
- analgesia
- amnesia
- paralysis
what impact does GA have on the pt’s airway
- cannot move or protect airway
what are 2 routes of admin for GA
- IV induction
- inhalation agents
describe IV induction for GA
- all routine GA procedures usually start w an IV induction
what is an example of GA given IV
- propofol
what is the foundation to anesthesia
- inhalation agents
how do GA inhalation agents enter the body (2)
- enter the body through the alveoli of the lungs
- most commonly admin via an endotracheal tube (placed once IV induction given)
what are 2 examples of inhalation agents for GA
- nitrous oxide
- flourine gas
what is given prior to intubation and insertion of endotracheal tube
- succinylcholine (muscle relaxant)
when does extubation occur
- after adjucts wear off
what are adjuncts to general anasthesia
- drugs added to IV regimen to achieve unconsciousness amnesia and muscle relaxation and ANS control
what are examples of adjuncts to general anesthesia (2)
- narcotics
- rocuronium (paralytic)
what impact does local anesthesia have on the body
- blocks electrical impulses along nerve fibers to specific part of body so that the procedure can be performed
what impact does LA have on the pt’s consciousness (2)`
- no loss of consciousness
- rapid recovery w little residual drug hangover
describe nutrition status prior to LA
- does not require pt to be NPO postop
what are 2 types of LA
- topical
- regional
describe topical LA
- application of anesthetic to skin or mucous membrane
what are types of regional LA (3)
- injection of a LA in or around nerve group such as brachial plexus
- spinal anasthetic
- epidural anesthetic
where is spinal anesthesia inserted into (3)
- infection of a local anesthetic into CSF in subarachnoid space
- one time injection of anesthetic and analgesia to subarachnoid space
- usually below L2
what does spinal anesthesia mix with
- CSF
what does spinal anesthesia block (3)
- autonomic
- sensory
- motor
= anything below lvl of spinal feels no pain, no motor response
what might a pt w spinal anesthesia experience
- vasodilation (d/t autonomic block)
what is an epidural (2)
- injection of anesthetic/analgesia in the epidural space
- drug binds to nerve roots entering/exiting spinal cord
what does an epidural block
- sensory fibers blocked
- motor fibers intact (pt can move)
describe use of an epidural
- can be a one-time dose for surgery
- can be left in to continue as analgesia for post-op (up to 3 days )
what is a spinal and epidural anesthetic often ysed for
- anesthesia for surgery of lower extremities
describe the impact of LA on resp system.
- pt can breath on own (no intubation needed)
what is required after a surgery w LA
- pain meds
what postop monitor for potential complications should be competed r/t spinal/epidural anesthesia (8)
- hypotension
- pruritis
- urinary retention
- NV
- infection/septicemia
- epidural hematoma
- spinal headache (w spinal)
- ensure epidural blocks arent too strong (can impact VS)
what does a spinal HA indicate
- CSF leakage
what is procedural (conscious) sedation
- mild or heavy deep IV sedation for minor surgical procedures or diagnostic procedures
what are examples of procedures that use procedural sedation (3)
- tooth extraction
- endoscopy
- wound debridement
what are 2 examples of meds used for procedural sedation (2)
- fentanyl
- versed (midazolam)
describe the impact of procedural sedation on the pts airway
- pt needs to maintain their own airway & breathing
describe the impact of procedural sedation on CNS (2)
- pt is awake
- pt may feel some discomfort
what should be monitored in a pt w procedural sedation (2)
- monitor VS (monitor for hypotension)
- monitor breathing
describe the nurses role w procedural sedation
- critical care or speciality training in conscious sedation
what are the goals of pt positioning intraop (3)
- optimize surgical exposure
- optimize to monitor for safety, give meds
- prevent injury and skin breakdown
what are ways to prevent injury & skin breakdown w positioning (5)
- provide good alignment
- secure extremities (velcro, seat belts)
- provide adequate padding and support (pstn may be for 8+ hrs)
- keep in mind areas where joints dont work well
- avoid straining self or pt when positioning
what is done before induction of anesthesia? who is the lead for this?
- briefing
- lead = circulator or anesthesiologist
what is included in briefing before induction of anathesia (8)
- pt verification (identity, consent, procedure, site)
- site marked/NA
- allergies & precautions
- VTE prophylaxis
- equipment/instrument/implant concerns
- difficult airway/aspiration risk?
- risk of >500 mL blood loss?
- postop destination
what is done before skin incision? who is the lead?
- time out
- lead = surgeon
what included in time out before skin incision (5)
- team members identified
- team verbally confirms pt, procedure, site
- antibiotic prophylaxis given within approp timeframe?
- team communicates anticipated complications
- any questions from the team?
what is done before the pt leaves the operating room
- debriefing
- lead = circulatior
what is done during debriefing (7)
- confirm procedure performed
- confirm ID and handling of specimen
- confirm instrument, sponge, and needle counts are correct (or na)
- any equipment problems
- surgeon review any imp intraop events & mngmt plans
- anesthesiologist any imp intraop events, recovery plans, normothermia maintained
- is there anything that could have been done better?
what is malignant hyperthermia
- rare and life-threatening event triggered by anesthetic
what anesthetic triggers malignant hyperthermia
- succinylcholine
what contributes to malignant hyperthermia
- genetic
when should risk of malignant hyperthermia be discovered
- in preop –> medical history info
“ have you or your family even had issues during surgery
what occurs w malignant hyperthermia
- body unable to regulate intracellular Ca when given syccinylcholine
what does malignant hyperthermia cause (8)
- hyperthermia
- hypermetabolism
- hypoxemia
- hypercarbia (increased CO2)
- tachycardia
- tachypnea
- dysrhytmias
- rigid skeletal muscles
what is the treatment for malignant hyperthermia
- dantrolene sodium (decreases metab)
- cool the pt
what is included in prevention of malignant hyperthermia
- family history
when does malignant hyperthermia occur
- within hour of induction
what is the “golden time”
- the time when postop problems are likely to show
- within 2 hr after surgery
what is the recovery room/post anesthesia care unit (PACU) (2)
- open area w stretchers, no walls, monitors, nurses charting at the bedside
- where the anesthesiologist brings the pt and gives report to RN
are visitors allowed in the PACU
- no
describe the location of the PACU; why is this beneficial
- close to OR = go back if needed or call anesthesiologist if surgeon to come assess pt
what is PACU discharge criteria (5)
- neuro baseline
- no resp depression
- sats >90%
- vitals stable
- no uncontrolled bleeding
