Ch 18 intraoperative Flashcards
1
Q
which allow for MIS, such as endovascular procedures, and the traditional open incision approach within the same room, are becoming more common.
A
Hybrid ORs
2
Q
(1) unrestricted, (2) semirestricted, and (3) restricted
A
Surgery department is divided into 3 distinct zones:
3
Q
is where people in street clothes interact with those in scrub attire. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station or control desk)
A
unrestricted zone
4
Q
includes the surrounding support areas and corridors. Only authorized staff are allowed access to semirestricted areas. All staff in the semirestricted area should wear clean surgical attire. This includes scrub attire that was laundered in an accredited laundry facility, long-sleeved jacket, shoes dedicated for surgery use or shoe covers, surgical head cover and mask that covers all head and facial hair, and any appropriate personal protective equipment (e.g., face shield)
A
semirestricted zone
5
Q
is found within the semirestricted area. It includes the surgical suite (OR) where the invasive procedure takes place and the sterile core
A
restricted zone
6
Q
, is an unrestricted zone where patient identification and assessment take place.
A
holding area, often called the preoperative holding area
7
Q
called the admission, observation, and discharge (AOD) unit
A
holding area is aka
8
Q
allow early morning admission for outpatient surgery, same-day admission, and inpatient holding before surgery
A
AOD (admission, observation, discharge) unit is designed to
9
Q
is controlled geographically, environmentally, and aseptically
A
restricted zone (description)
10
Q
Filters and controlled airflow in the ventilating systems provide dust control. Positive air pressure in the rooms prevents air from entering the OR from the halls and corridors. ORs are kept within a narrow range of temperature and humidity to prevent bacteria growth. ORs follow strict protocols for cleaning between cases and terminal cleaning at the end of the day. The use of ultraviolet lighting reduces the number of microorganisms in the air.2
A
methods to prevent the transmission of infection in the OR
11
Q
offers a way to deliver routine and emergency messages
A
communication system (OR)
12
Q
is a registered nurse (RN) who collaborates with the rest of the surgical team and implements the patient’s plan of care during perioperative period
A
perioperative nurse
13
Q
Depending on the size of the OR department
(1) preoperative RN, (2) OR RN, and (3) PACU RN.
A
Preoperative RN role may include three domains: (vary upon size)
14
Q
(1) maintaining the patient’s safety, dignity, and confidentiality; (2) communicating with the patient, the surgical team, and other departments (e.g., CPD, PACU, laboratory); and (3) providing nursing care discussed in the Nursing Management section of this chapter.
A
OR RN, you are the patient’s advocate during surgery. This includes
15
Q
follows the designated surgical hand antisepsis and glove and gown sterile attire and prepares and manages the sterile field and instrumentation
A
scrub nurse (sterile)
16
Q
assumes functions that involve either sterile or unsterile activities
A
OR RN
17
Q
stays in the unsterile field, facilitates the progress of the procedure, and keeps documentation
A
circulating nurse
18
Q
may fill the role of the circulating or scrub nurse
A
LPN/VN or a surgical technologist
19
Q
performing delegated nursing tasks.7
A
As an OR RN, you take on responsibility for supervising an LPN/VN or surgical technologist
20
Q
• Preoperative medical history and physical assessment, directing preoperative testing, and postoperative management Obtaining informed consent
• Leading the surgical team and directing the course of a procedure
A
surgeon is primarily responsible for
21
Q
another physician, registered nurse first assistant (RNFA), physician’s assistant, surgical resident or fellow, medical student, or a certified surgical first assistant.
A
surgeon’s assistant can be
22
Q
usually holds retractors to expose surgical areas and helps with hemostasis and suturing. In some agencies, especially in educational settings, the assistant may perform some portions of the surgery under the surgeon’s direct supervision.
A
surgeons assistant scope
23
Q
to achieve an optimal surgical outcome for the patient.
A
registered nurse first assistant (RNFA) works with the surgeon
24
Q
CNOR nurses or nurse practitioners can complete RNFA program to assume this expanded role. RNFAs can obtain
A
certification (C-RNFA). (to work collaboratively with surgeon
25
is a medical specialty that focuses on clinical management of the patient in the perioperative period, pain management, critical care, trauma, airway management, and cardiopulmonary resuscitation.
Anesthesiology
26
is the person responsible for administering anesthetic agents and managing vital life functions (e.g., breathing, BP) during the perioperative period. This can be an anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA).
anesthesia care provider (ACP)
27
who has graduated from an accredited nurse anesthesia program and completed a national certification examination to become a certified registered nurse anesthetist (CRNA).
nurse anesthetist is a master’s or a doctorate prepared RN
28
is a master’s or a doctorate prepared RN who has graduated from an accredited nurse anesthesia program and completed a national certification examination to become a certified registered nurse anesthetist (CRNA).
nurse anesthetist
29
• Performing and documenting a preanesthetic assessment and evaluation
• Developing and implementing a plan for delivering anesthesia
• Choosing, obtaining, and administering anesthesia, adjuvant drugs, and fluids
• Choosing, applying, and inserting appropriate monitoring devices
• Managing a patient’s airway and pulmonary status
• Managing emergence and recovery from anesthesia
• Releasing or discharging patients from a PACU
• Ordering, starting, or modifying pain relief therapy
• Responding to emergency situations by providing airway management
CRNA’s scope of practice includes:
30
is a master’s-prepared health professional who serves under the direction of an anesthesiologist
AA (anaesthesia assistant)
31
is responsible for implementing the intraoperative plan of care and serving as the patient’s advocate. The circulating nurse focuses on the whole patient. This involves ongoing assessment, reassessment, and adjusting the care plan to promote the best surgical outcomes.
circulating nurse duty for intraoperative
32
Any retained surgical supplies, devices, or instruments are sentinel events (never events) or serious reportable events (SREs) that can result in negative outcomes for the patient.
sentinel events (never events)
33
in many agencies. When using an alcohol-based surgical hand-scrub product, prewash hands and forearms with soap and dry completely before applying the alcohol-based product. After applying the alcohol-based product, rub hands and forearms thoroughly until dry before donning sterile attire.1,4
Waterless, alcohol-based agents are replacing soap and water
34
is required of all sterile members of the surgical team (scrub nurse, surgeon, assistant)
Surgical hand antisepsis
35
your finger nails are cleaned first, followed by scrubbing each plane of individual fingers, palms, and forearms in the distal to proximal fashion. The hands should always be held away from surgical attire and higher than the elbows
wet scrubbing is the chosen method for surgical hand antisepsis,
36
(1) standard and transmission-based precautions, (2) engineering and work practice controls, and (3) the use of personal protective equipment, such as gloves, gowns, caps, face shields, masks, and protective eyewear. This is especially important in the OR because of the high potential for exposure to blood-borne pathogens.
OSHA guidelines for protection against blood-borne pathogens
37
are the front from chest to table level and sleeves to 2 inches above elbow.
only parts of the gown considered sterile
38
is used for various gynecological, genitourinary, and colon procedures.
lithotomy position (during surgery)
39
Positioning is a critical part of every procedure and usually follows induction of anesthesia. The
ACP says when to begin positioning
40
supine, prone, lateral, lithotomy, or sitting. The supine is the most common position
variety of surgical positions, including
41
Take care to (1) provide correct musculoskeletal alignment; (2) prevent undue pressure on nerves, skin over bony prominences, earlobes, and eyes; (3) provide for adequate thoracic excursion; (4) prevent occlusion of arteries and veins; (5) provide modesty in exposure; and (6) recognize and respect individual needs, such as previously assessed pains or deformities.
take great care to prevent injury to the patient
42
peripheral vessels to dilate
General anesthesia causes
43
Position changes affect where the pooling of blood occurs. If the head of the OR bed is raised, the lower torso will have increased blood volume and the upper torso may become compromised
General anesthesia causes dilation of vessels
44
Excess hair, adipose tissue, bony prominences, fluid (edema), adhesive failure, and scar tissue can compromise safety
electrosurgical unit is in use, the patient must be properly grounded to prevent unintended injury
45
reduce the number of microorganisms available to migrate to the surgical wound. The circulating nurse, surgeon, or surgical assistant completes the task of prepping before surgery.
purpose of skin preparation, or “prepping,” is to
46
there is strong research supporting that nontechnical skills (NTS) also have a high impact on outcomes
technical skills, such as operating equipment or proper instrument handling, are a critical part of OR RN competency,
47
proper and clear communication, teamwork, situational awareness (e.g., anticipatory cognitive skills), and stress and fatigue management.1
nontechnical skills (NTS)
48
is a national quality partnership of organizations focused on improving surgical care by significantly reducing the number of complications from surgery
Surgical Care Improvement Project (SCIP)
49
(1) a prophylactic antibiotic started within 30 to 60 minutes before the surgical incision to decrease risk for infection, (2) applying a warming blanket to prevent unintended hypothermia, and (3) applying intermittent pneumatic compression devices (IPCs) to minimize the risk for VTE.
Specific SCIP measures include
50
require a preprocedure verification process. This includes verification of relevant documentation (e.g., history and physical examination, signed consent forms, nursing and preanesthetic assessment) and the results of any diagnostic studies (e.g., x-rays, biopsy reports). Any needed blood products, implants, devices, and special equipment must be available.
National Patient Safety Goals (NPSGs)
51
, is followed to prevent wrong site, wrong procedure, and wrong patient. Wrong surgical procedure and surgery on the wrong body part or wrong patient are sentinel events (never events) or SREs
Universal Protocol, one of the NPSGs
52
defines anesthesia according to the effect that it has on the patient’s sensorium and pain perception
American Society of Anesthesiologists (ASA)
53
definitions include minimal sedation (e.g., anxiolysis), moderate sedation/analgesia, deep sedation/analgesia, and general anesthesia
effect that it has on the patient’s sensorium and pain perception
54
allows ACPs to track the level of patient awareness (i.e., awareness monitoring) during surgery and adjust anesthesia as needed.
noninvasive electroencephalogram-based technology
55
the ACP in collaboration with the surgeon and patient
anesthetic technique and agents are chosen by
56
the patient’s current physical and mental status, age, allergies, pain history, expertise of the ACP, and factors related to the procedure (e.g., length, site, discharge plans).
ACP has ultimate responsibility for the choice of anesthesia Contributing factors include
57
moderate to deep sedation, monitored anesthesia care (MAC), general anesthesia, and local and regional anesthesia
Types of anesthesia techniques include
58
is used for procedures done outside of the OR
-Trained RNs who are allowed by agency protocols and state nurse practice acts can provide this type of anesthesia.
Moderate to deep sedation
59
used for diagnostic or therapeutic procedures done in or outside of the OR (e.g., endoscopy clinic).
Monitored anesthesia care (MAC)
60
It includes varying levels of sedation, analgesia, and anxiolysis
-provider of MAC must be an ACP since it may be necessary to change to general anesthesia during the procedure.
Monitored anesthesia care (MAC)
61
(1) control of excessive biologic responses induced by a variety of stressors and (2) protection of patients from stress-induced complications.
goals of anesthesiology include the
62
and newer inhalation agents have a fast onset, fast elimination, and fewer undesirable side effects than earlier agents. These factors promote early discharge from the PACU and ambulatory surgery centers.
total intravenous anesthesia (TIVA)
63
is the technique of choice for patients who are having surgical procedures that are of significant duration, need skeletal muscle relaxation, require uncomfortable operative positions because of the location of the incision site, or require control of ventilation. Other reasons include patient refusal of local or regional techniques, contraindications to other techniques, and uncooperative patients.
General anesthesia
64
to intoxication, emotional lability, head injury, impaired cognition, or inability to remain immobile for any length of time
patients may be uncooperative due
65
may be induced by IV or inhalation and maintained by either or a combination of the two
General anesthesia
66
General anesthesia may be induced by IV or inhalation and maintained by either or a combination of the two
most common approach used for general anesthesia.
67
agent, whether it is a hypnotic, an anxiolytic, or a dissociative agent.
All routine general anesthetics begin with an IV induction
68
Inhalation agents
cornerstone of general anesthesia.
69
One undesirable trait is the irritating effect some inhalation agents (e.g., desflurane [Suprane]) have on the respiratory tract. Complications include coughing, laryngospasm, and increased secretions.
desflurane [Suprane) //volatile (general anaesthesia)
70
allows control of ventilation and protects the airway from aspiration.
ET tube (given w/IV anaesthesia)
71
allows control of ventilation and protects the airway from aspiration.
-better for airway and trachea than LMA
ET tube aka endotracheal (given w/IV anaesthesia)
72
are currently an important option for patients with difficult airways, but they do not provide access to the trachea or airway protection with the same certainty as ETs. Complications of ET tube or LMA use are primarily related to insertion and removal. These include failure to intubate, damage to teeth and lips, laryngospasm, laryngeal edema, sore throat, and hoarseness caused by injury or irritation of the vocal cords or surrounding tissues.
LMAs ( laryngeal mask airway)
73
Drugs added to an inhalation anesthetic (other than an IV induction drug) are termed
adjuncts
74
are added to the anesthetic regimen to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or autonomic nervous system control.
Adjuncts achieve
75
They include opioids, benzodiazepines, neuromuscular blocking agents (muscle relaxants), and antiemetics
the adjuncts added to the anesthetic regimen are following
76
interrupts associative brain pathways while blocking sensory pathways
Dissociative anesthesia
77
is a common dissociative anesthetic.
- promotes bronchodilation
- Concurrent use of midazolam (Versed)
Ketamine (Ketalar) (given IV or IM)
78
interrupts the generation of nerve impulses by changing the flow of sodium into nerve cells.
Local anesthesia
79
autonomic nervous system blockade, anesthesia, and skeletal muscle flaccidity or paralysis
Local anesthesia
80
are topical, ophthalmic, nebulized, or injected
-It does not involve sedation or loss of consciousness
Local anesthetics
81
using a local anesthetic is always injected.
Regional anesthesia (or block
82
involves a central nerve (e.g., spinal) or group of nerves (e.g., plexus) that innervate a site remote to the point of injection.
Regional anesthesia (or block
83
may involve concurrent use of MAC or moderate to deep sedation
Administration of a local or regional anesthetic
84
preoperative analgesia, during surgery to manage surgical pain, and after surgery to control pain.
Regional blocks are used as
85
that deliver local anesthetic to the surgical site through a pump implanted during surgery can give continuous pain relief up to 72 hours after surgery.
Indwelling catheters
86
rapid recovery and discharge with continued postoperative analgesia without any accompanying cognitive dysfunction. They can be safely used in patients who have co-morbidities that prevent the use of general anesthesia.
Advantages of local and regional anesthesia include
87
include the potential for technical problems, discomfort at the injection site, and the inability to precisely match the agent’s duration of action to the duration of the procedure. Another disadvantage is the risk for inadvertent vascular injection leading to local anesthetic systemic toxicity (LAST)
Disadvantages local and regional anesthesia include
88
confusion, metallic taste, oral numbness, and dizziness.17 Without treatment, seizures, coma, and dysrhythmias may occur.
local anesthetic systemic toxicity LAST first presents as
89
topical applications of creams, ointments, aerosols, and liquids
-The drug is applied directly to the skin, mucous membranes, or open surface. Eutectic mixture of local anesthetics (EMLA cream, a combination of prilocaine and lidocaine) is an example. It is applied to the site 30 to 60 minutes before a procedure.
standard methods to administer local anesthesia.
90
success of injected local anesthetics may be limited by prolonged duration of procedure or infection at the injection site that interferes with drug absorption.
local anesthesia. IV
91
This decreases absorption and extends the action of the agent. However, if the local anesthetic is absorbed in the tissues or inadvertently injected IV and enters the general circulation, the patient may have tachycardia, hypertension, and a general feeling of panic.
Some local anesthetics are combined with epinephrine to provide localized vasoconstriction.
92
brachial plexus block; IV regional anesthesia (IVRA) or Bier block anesthesia; and femoral, axillary, cervical, sciatic, ankle, and retrobulbar blocks.
Examples of common regional nerve blocks include
93
the patient has a double-cuff tourniquet applied as a safety measure.
For IVRA or Bier block,
94
regional anesthesia
Spinal anesthesia and epidural anesthesia are also types of
95
the injection of a local anesthetic into the cerebrospinal fluid in the subarachnoid space, usually below the level of L2
Spinal anesthesia involves
96
(e.g., joint replacements) and lower gastrointestinal, prostate, and gynecologic surgeries.
spinal anesthetic may be used for procedures involving the extremities
97
injection of a local anesthetic into the epidural space via a thoracic or lumbar approach
epidural block involves
98
anesthetic agent does not enter the cerebrospinal fluid but binds to nerve roots as they enter and exit the spinal cord. With the use of a low concentration of local anesthetic, sensory pathways are blocked but motor fibers are still intact. In higher doses, sensory and motor fibers are blocked.
epidural block pathophysiology
99
analgesia or in combination with MAC or general anesthesia, in obstetrics, vascular procedures involving the lower extremities, lung resections, and renal and midabdominal surgeries.
Epidural anesthesia is often used for
100
is more rapid than that of epidural anesthesia. Both may be extended in duration using indwelling catheters, thus allowing for more doses of anesthetic.
onset of spinal anesthesia vs epidural anaesthesia
101
less autonomic nervous system blockade with epidural anesthesia than with spinal anesthesia.
epidural vs spinal anaesthesia
102
anesthetic agents have become safer and more predictable, the aging process affects the absorption, distribution, and metabolism of drugs.
- results in changes in their onset, peak, and duration independent of the route of administration.
Gerontologic Considerations:
103
may also change the patient’s response to blood and fluid loss and replacement, hypothermia, pain, and tolerance of the procedure and positioning
Physiologic changes in aging
104
is a common complication in this population and associated with adverse surgical outcomes
Postoperative delirium
105
injury from tape, electrodes, warming and cooling blankets, and certain types of dressing
Because of decreased ability to perceive discomfort or pressure on vulnerable areas and a loss of skin elasticity, the older adult’s skin is at risk for
106
is the most severe form of an allergic reaction, manifesting with life-threatening pulmonary and circulatory complications. ACPs give patients a variety of drugs, including anesthetics, antibiotics, and blood products.
Anaphylaxis
107
manifestations of anaphylaxis
Anesthesia may mask the initial
108
hypotension, tachycardia, bronchospasm, and pulmonary edema.
anaphylactic reaction causes
109
is a rare disorder characterized by hyperthermia with skeletal muscle rigidity
Malignant hyperthermia (MH)
110
Succinylcholine (Anectine), especially when given with volatile inhalation agents, is the
primary trigger of MH. /Malignant hyperthermia
111
MH does occur, it is usually during general anesthesia. It may occur in the recovery period, too.
Succinylcholine (Anectine), cause MH during
112
Other factors include stress, trauma, and heat.
other causes Malignant hyperthermia
113
from altered control of intracellular calcium. This leads to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac problems. Tachycardia, tachypnea, hypercarbia, and ventricular dysrhythmias may occur
fundamental defect is hypermetabolism of skeletal muscle resulting (cause of Malignant hyperthermia)
114
prompt administration of dantrolene (Dantrium, Ryanodex)
definitive treatment of MH is
115
slows metabolism, reduces muscle contraction, and mediates the catabolic processes associated with MH.
Dantrolene (treatment for MH)
116
It is variable in its genetic manifestation, so predictions based on family history are important but not reliable.
MH//Malignant hyperthermia ( is an autosomal dominant trait.
