Older Adults Pt 2 > 3.2 Intraoperative Care > Flashcards

3.2 Intraoperative Care Flashcards

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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.
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2
Q

Open Surgery

A
  • Incisions large enough to allow surgeon to see areas necessary for the surgery.
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3
Q

Minimally Invasive Surgery (MIS)

A
  • This and robotic surgery are now common practice

- MIS is preferred method

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4
Q

INTRAOPERATIVE AREAS

A
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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
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6
Q

Semi-Restricted

A
  • Only authorized personnel are permitted

- Scrub clothes and Caps are required

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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.
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8
Q

Members of Surgical Team

A 
Patient
Anesthesiologist (physician) or CRNA (nurse anesthesiologist) 
Surgeon 
Certified Surgical Technologists 
Nurses
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9
Q

Perioperative Nurse

A
  • Communication with patient and inpatient unit nurses
  • Prepares OR team for patient
  • Patient Advocate
  • Patient Education
  • Documentation Care
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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
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11
Q

Scrub Nurse

A
  • Manages OR functions within sterile field
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12
Q

Registered Nurse First Assistant (RNFA)

A
  • Requires formal education

- Collaborates with surgeon and handles tissue, uses instruments, manages homeostasis, does suturing.

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13
Q

Surgical Technician

A
  • May be filled by LPN, Tech, or RN

- Passes instruments to the surgeon

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14
Q

Certified RN Anesthesiologist (CRNA)

A
  • Masters Degree
  • National certification
  • Administers anesthesia and intubates patient
  • Monitor patient continuously throughout surgery
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15
Q

“Time Out” Second Time

A
  • Done in the OR

- Verify patient ID, informed consent, health history, diagnostic tests, allergies, surgical site

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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
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17
Q

Protection from Infection

A
  • First line of defense is environmental controls
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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.
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19
Q

Hyperoxia

A
  • Administration of high levels of oxygen

- Not recommended to reduce surgical site infections

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20
Q

NURSING MANGEMENT DURING SURGERY

A
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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
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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
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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.
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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
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25
Anesthesia
- 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.
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General Anesthesia
- 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.
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Regional Anesthesia
- Loss of sensation to a region of the body without loss of consciousness such as epidural or a peripheral nerve block.
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Monitored Anesthesia Care (MAC)
- Similar to general anesthesia but used for therapeutic and diagnostic procedures. (Colonoscopy)
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Neuromuscular Blockers
- Used for paralysis only, or during mechanical ventilation
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Local Anesthetics
- Blockage of a particular sensory transmission to CNS. | - Used for minor surgeries in conscious state
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Moderate Sedation
- Depresses LOC - Patient can follow commands and protective reflexes remain intact - Used to reduce pain and anxiety during medical procedure
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Three phases of General Anesthesia
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.
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4 STAGES OF GENERAL ANESTHESIA
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Stage 1 - Analgesia
- Decreases pain transmission | - Conscious and able to converse
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Stage 2 - Excitement
- Systolic BP increase - Excitation and restlessness - Possible decreased respiratory rate - Delirium - Usually overcome with sedation
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Stage 3 - Surgical Anesthesia
1. Regular respirations, beginning of muscle relaxation (light anesthesia) 2. Spontaneous respiration ceases (loss of reflex) 3. Deep anesthesia (shallow breathing, may require ventilation) 4. Breathing may stop entirely
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Stage 4 - Overdose/Medullary Depression
- Respiratory and vasomotor centers are depressed - Respirations have ceased - Coma and death will follow without rapid intervention and support
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Inhaled General Anesthesia
- Isoflurane, Sevoflurane, Desflurane (fluranes) are Halogenated Ethers - Halothane is a Halogenated Hydrocarbon - Nitrous Oxide
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Intravenous General Anesthesia
- Propofol (Diprivan) - Fentanyl - Midazolam (Versed)
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Inhaled Anesthetics
- Ideally produces unconsciousness, muscle relaxation, and amnesia - Induction and Emergence are brief - Depth is easily adjusted - Adverse events minimal - Large margin of safety
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Pharmacokinetics Inhaled Anesthetics
- 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
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Adverse Effects Inhaled Anesthetics
- Respiratory/Cardiac Depression - Sensitization of heart to catecholamines, malignant hyperthermia, aspiration of gastric content, hepatotoxicity, toxicity to operating room personnel.
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Interactions of Inhaled Anesthetics
- CNS depressants/stimulants (influence amount required) | - Opioids (lessen amount required)
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Balanced Anesthesia
- 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.
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Isoflurane
- 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
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Halothane
- 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
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Nitrous Oxide
- 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.
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Adjuncts to Inhalation Anesthesia
- Preanesthetic Medications to reduce anxiety, induce amnesia, relieve pre/post operative pain - Benzodiazepines, opioids, clonidine, alpha 2 adrenergic agonist, anticholinergic drugs.
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Propofol (Diprivan)
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
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Ketamine (Kelalar)
- 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 -
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Moderate Sedation/Analgesia
- 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.
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Local Anesthesia
- 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.
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Amides
- 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
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Esters
- Novocain, procaine, benzocaine (short acting) - Tetracaine (long acting) - Metabolized in serum by esterases - Causes high risk of allergic reactions and systemic toxicity
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Local Anesthetic Administration
- Topical application, local infiltration, regional injection
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Regional Injections
- Peripheral Nerve Blocks - IV Regional Blocks - Spinal Anesthesia - Epidural Anesthesia
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Lidocaine
- 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.
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Adverse Effects of Surgery and Anesthesia
- 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.
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Catastrophic Events
- 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
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Malignant Hyperthermia (MH)
- 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
Older Adults Pt 2
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