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INTRAOPERATIVE PHASEIntraoperative Phase- Transferred to OR-ends with the transfer to the recovery area.Transfer onto the operating tablePhases of anesthesiaOperative proceedureTransfer from operating table to stretcherSafe transport to post-operative area (PACU)2 SURGICAL TEAMSurgeonAnesthesiologistScrub NurseCirculating NurseOR techsSurgical teamSurgeon-responsible for determining the preoperative diagnosis, the choice and execution of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management of the patients care.Scrub nurse- (RN or Scrub tech)- preparation of supplies and equipment on the sterile field; maintenance of pt.s safety and integrity: observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile instrumentation, sutures, and supplies; sharps count.

Surgical teamCirculating Nurse - responsible for creating a safe environment, managing the activities outside the sterile field, providing nursing care to the patient. Documenting intraoperative nursing care and ensuring surgical specimens are identified and place in the right media. In charge of the instrument and sharps count and communicating relevant information to individual outside of the OR, such as family members.Surgical teamAnesthesiologist and anesthetist- anesthetizing the pt. providing appropriate levels of pain relief, monitoring the pts physiologic status and providing the best operative conditions for the surgeons.Other personnel- pathologist, radiologist, perfusionist, EVS personnel.Nursing Roles:Staff educationClient/family teachingSupport and reassuranceAdvocacyControl of the environmentProvision of resourcesMaintenance of asepsisMonitoring of physiologic and psychological statusElements of Aseptic Technique*Sterile gowns and gloves.*Sterile drapes used to create sterile field.*Sterilization of items used in sterile field.Surgical asepsisThe absence of pathogenic microorganisms.Ensure sterilityAlert for breaksThe practice of aseptic technique requires the development of sterile conscience, an individuals personal honesty and integrity with regard to adherence to the principles of aseptic technique.

Preanesthetic PreparationAvoidance of foods and drink prevents passive regurgitation of gastric contentsClients should typically continue medications up to surgeryConsent must be received10SedationReduction of stress, excitement, or irritability and some suppression of CNSTypically used to relieve anxiety and discomfort during a procedureResidual effects include amnesia and letheragy11Types of AnesthesiaRegionalLocalNerve blockEpiduralSpinalGeneral Spinal AnesthesiaInjected into cerebrospinal fluid (approx L 3-5) subarachnoid space

Indications-surgical procedures below the diaphragm-patients with cardiac or respiratory diseaseAdvantages-mental status monitoring-shorter recoveryDisadvantages-necessary extra expertise-possible patient painContraindications-coagulopathy-uncorrected hypovolemia

Spinal AnesthesiaInvolved medications-lidocaine-bupivacaine-tetracainePatient assessment-continuous heart rate, rhythm, and pulse oximetry monitoring-level of anesthesia-motor function and sensation return monitoring

Spinal AnesthesiaComplications-hypotension-bradycardia-urine retention-postural puncture headache-back pain

Spinal Anesthesia (Subarachnoid Block)Anesthesia: tip of xiphoid to toesRisks:Loss of vasomotor toneSpinal HeadacheInfection, Rising anesthesia above diaphragmNursing: KEEP FLAT, MONITOR VS & OFFER FLUIDS WHEN APPROPRIATE

16General AnesthesiaInhalation-Mask, Endotracheal tube (ETT) or Laryngeal managed airway (LMA)IntravenousCombination17General Anesthesia: Inhalation AgentsInhalation most controllable method; lungs act as passageway for entrance & exit of agentGas Agents : Nitrous Oxidemust be given with oxygenrequire assisted to mechanical ventilationfrequently shivertaken in & excreted via lungsExamples: halothane, enthrane, florane18Adjuncts to General AnesthesiaHypnotics (Versed, Valium)also used for conscious sedationOpioid Analgesics (morphine, Demerol)respiratory depressionNeuromuscular Blocking AgentsCauses muscle paralysisExamples: Pavulon, SuccinycholineWhat vital function is affected? 19Potential General Anesthesia ComplicationsOverdose (consider risk factors)Hypoventilation postoperativelyIntubation related: sore throat, hoarseness, broken teeth, vocal cord traumaMALIGNANT HYPERTHERMIAGenetic predispositionTriggered by anesthetics such as Halothane20Potential Intraoperative ComplicationsNausea and vomitingAnaphylaxisRespiratory complicationsInadequate ventilation, airway occlusion, intubation of the esophagus, and hypoxiaHypothermiaMalignant hyperthermiaDisseminated Intravascular Coagulation

What are measures to prevent or treat these complications?21Nursing InterventionsCommunicating plan of careIdentifying nursing activitiesEstablishing prioritiesCoordinate care with team membersCoordinate supplies and equipmentControl environmentDocument plan of careIntraoperative Nursing CareRisk of infection related to invasive procedure and exposure to pathogens.Risk for injury related to positioning during surgery.Risk of injury related to foreign objects inadvertently left in the wound.Risk for injury related to chemical, physical, and electrical hazards.Risk for impaired tissue integrity.Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status.Nurses are responsible for managing six areas of risk:23Nursing Process Intraop PhaseInterventionSafetyAdvocacyVerificationCounting-instruments, sponges, needles

24Altered Skin IntegrityHow many sutures?Staples or sutures or glue???

25POSTOPERATIVE PHASE Postoperative- Begins with transfer to PACU and ends with the discharge of the patients from the surgical facility or the hospital.Nursing InterventionsCommunicating pertinent information about surgery to the PACU staff.Postoperative evaluation in clinic or home.Nursing assessment in the Recovery RoomVital signs- presence of artificial airway, o2 sat,BP,pulse, temperature.Ability to follow command, pupillary responseUrinary outputSkin integrityPainCondition of surgical woundPresence of IV linesPosition of patientImmediate Post-anesthesia CareAirwayBreathingCirculation

How often should vital signs be assessed?29Postop SKIN AssessmentAltered Skin IntegrityDay 3 or so to Day 14 (or 21 or more)Proliferation: fibrin strands form scaffoldCollagen with blood = granulation tissueProtect from damage or stress No lifting, heavy exercise, driving etc.At risk for dehiscence or eviscerationDay 15 (or weeks, months, years)Scar is organized, less red, strongerMax strength = 70 80% 30Postoperative RESPIRATORY AssessmentImpaired gas exchange or impaired airway clearanceRisks: pneumonia, atelectasisAssessment: Open airwayPulse oximetry (what is normal?)Check opioid use (why?)Monitor quality & quantity of respirations31Postoperative RESPIRATORY AssessmentInterventions:Turn (also relates to cardiovascular risk any ideas?)Deep breathe & coughIncentive spirometryIn-bed exercises (see text)AMBULATION!!

32Postop SKIN AssessmentAltered Skin IntegrityWound healingHow is the face healing time-line different from the foot?OR to Day 2 (may 3-5)Inflammation vs. infectionredness, pain, swelling, warmthskin held together by blood clots & tiny new blood vesselsAvoid pressure/ be sure to splint

33Postop CARDIOVASCULAR Assessment: Potential for hypoxemiaThink (hypovolemic) shock (hemorrhage) Assessment: Prevention of venous stasis Who is at risk? What should be done?

34Avoiding Venous StasisAvoidance of positions leading to venous stasisIn Bed ExercisesAntiembolism stockingsSequential Compression DeviceWhen all is said & done, AMBULATION is the best!

35Postop NEUROLOGIC AssessmentAssess cerebral functionThink elderlyAssess motor/sensory function

36Postop F & E AssessmentFluid Status IntakeOutputWhy would a postop client need an IV??

37Postop URINARY AssessmentAnuria (define) Urinary Retention Or Urinary retention with overflowDifferentiateIntervention:FluidsAMBULATIONCareful monitoring38Postop GI AssessmentNausea & vomitingAssessment of peristalsis/paralytic ileusInterventions:N/G tube, GI rest (NPO), AMBULATIONPostop DietsWhy are clear liquids usually the first diet?What does advance as tolerated mean?What are nursing responsibilities??

39Postoperative Diets 1. Clear Liquid2. Full Liquid3. Soft4. RegularPostop DietsWhy are clear liquids usually the first diet?What does advance as tolerated mean?What are nursing responsibilities??

40Postop SKIN AssessmentAltered Skin IntegrityR ednessE demaE cchymosisD rainageA pproximationIs a scar as strong as the original skin?

41The Ultimate in Altered Skin IntegrityRisk factors: -Dehiscence-EviscerationPrevention:-Wound Splinting-Abdominal binder-Diet

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Nursing DiagnosisIneffective airway clearance- increased secretions 2 to anesthesia, ineffective cough, painIneffective breathing pattern- anesthetic and drug effects, incisional painAcute painUrinary retentionRisk for infectionPostoperative GoalsRe-establishment of physiologic equilibriumAlleviation of painPrevention of complications44Postoperative ManagementMaintain a patent airwayStabilize vital signsEnsure patient safetyProvide painRecognize & manage complications

When caring for post-surgical patient, think of the 4 WsWind: prevent respiratory complicationsWound: prevent infectionWater: monitor I & OWalk: prevent thrombophlebitisComplicationsRespiratory- atelectasis, pulm. EmbolusCardiovascular- venous thrombosisGastrointestinal-Hiccoughs, N/V,abd. Distention, paralytic ileus, stress ulcer.GU- urinary retentionHemorrhage-slipping of a ligature(suture)Wound infection-Wound dehiscence and evisceration-Postoperative Pain ControlWhat is the definition of Pain?

As nurses, what do we need to remember about the pain experience?

What is the key reason to control postoperative pain? 48

49Thank you