INTRA OPERATIVE CARE OF A PATIENT PRESENTED BY OLUKOYA MARY BUSOLA AND AWONUSI MONSURAT 1 Intraoperative Care 2 Physical Environment • Surgical suite • Controlled environment • Designed to minimize spread of infections • Allows smooth flow of patients, personnel, and instruments/equipment 3 Physical Environment • Unrestricted areas • Personnel in street clothes interact with those in scrubs • Holding and information areas 4 Physical Environment • Semi-restricted areas • Peripheral support areas and corridors with only authorized people • Must wear surgical attire and cover all head and facial hair 5 Physical Environment • Restricted areas • Operating rooms • Scrub sink areas and clean core • Masks required 6 Physical Environment • Holding area • Waiting area inside or adjacent to surgical area • Final identification and assessment • Minor procedures performed • Friends/family allowed 7 Physical Environment • Operating room • Geographically, environmentally, bacteriologically controlled • Restricted in inflow and outflow of personnel • Preferred location is next to postanesthesia care unit 8 Surgical Team • Perioperative nurse • Prepares room with team • Patient advocate throughout surgical experience 9 Surgical Team • Circulating nurse • Not scrubbed, gowned, or gloved • Remains in unsterile field • Documents 10 Surgical Team • Scrub nurse • Follows designated scrub procedure • Gowned and gloved in sterile attire • Remains in sterile field 11 Surgical Team • Surgeon • Physician who performs the procedure • Responsible for: • Preoperative medical history • Physical assessment • Patient safety 12 Surgical Team • Surgeon’s assistant can be physician or RN who functions in assisting role • Holds retractors • Assists with hemostasis and suturing • May perform portions of procedure under direct supervision 13 Surgical Team • Anesthesia care provider • Administers anesthesia • Anesthesiologist or nurse anesthetist • Maintenance of physiologic homeostasis throughout intraoperative period 14 Nursing Management • Before surgery • Psychosocial assessment • Physical assessment • Chart Review 15 Nursing Management • Chart review • History and PE • Urinalysis • CBC • Serum electrolytes • Chest x-ray • ECG 16 Nursing Management • Chart review • Diagnostic tests (i.e., CT scan) • Pregnancy testing • Surgical and blood transfusion consent • Allergies • Blood type and crossmatch 17 Nursing Management • Room preparation • Surgical attire worn by all persons entering OR suite • Electrical and mechanical equipment checked for proper functioning 18 Nursing Management • Aseptic technique practiced with placing instruments • Counts • Delineation of team members 19 Nursing Management • Basic aseptic technique • Center of sterile field in surgical incision • Only sterilized items in sterile field • Face shields • Caps, gloves, aprons, eyewear 20 Nursing Management • Positioning of patient • Accessibility of operative site • Administration and monitoring of anesthetic agents • Maintenance of airway • Correct skeletal alignment 21 Commonly Used Intra Op Positions 22 Nursing Management • Prevent pressure on nerves, skin over bony prominences, eyes • Provide for adequate thoracic excursion • Prevent occlusion of arteries and veins • Provide modesty in exposure • Recognize and respect needs such as pain or deformities 23 Nursing Management • Prevent injury • Patient will not feel pain impulses due to anesthesia • Secure extremities • Provide adequate padding and support 24 Classification of Anesthesia • • • • General anesthesia Local anesthesia Regional anesthesia Conscious sedation 25 Classification of Anesthesia • General Anesthesia • Loss of sensation with loss of consciousness • Skeletal muscle relaxation • Analgesia 26 Classification of Anesthesia • General anesthesia • IV induction agents • Induce pleasant sleep • Rapid onset • Inhalation agents • Enter body through alveoli • Rapid excretion by ventilation 27 Classification of Anesthesia • Adjuncts to general anesthesia • Opioids • Pre-op: Sedation and analgesia • Intra-op: Induction & maintenance • Post-op: Pain management • Respiratory depression 28 Classification of Anesthesia • Adjuncts to general anesthesia • Benzodiazapines • Premedication for amnesia • Induction of anesthesia • Conscious sedation • Supplemental IV sedation during local and regional anesthesia • Anxiety and agitation 29 Classification of Anesthesia • Adjuncts to general anesthesia • Neuromuscular blocking agents • Facilitate endotracheal intubation • Relaxation/paralysis of skeletal muscles • Interrupt transmission of nerve impulses at neuromuscular junction 30 Classification of Anesthesia • Adjuncts to general anesthesia • Antiemetics • Prevent nausea and vomiting associated with anesthesia 31 Classification of Anesthesia • Local anesthesia • Loss of sensation without loss of consciousness • Topically • Intracutaneously • Subcutaneously 32 Classification of Anesthesia • Spinal anesthesia • Injection of agent into CSF in subarachnoid space • Usually below L2 • Autonomic, sensory, and motor blockade • May become hypotensive from vasodilation 33 Classification of Anesthesia • Epidural block • Injection of agent into epidural space • Does not enter CSF • Binds to nerve roots as they enter and exit the spinal cord • Patient can remain fully conscious 34 Classification of Anesthesia • Observe closely for signs of autonomic nervous system (ANS) blockade • Bradycardia • Hypotension • Nausea/vomiting • Decreased incidence of headache associated with spinal anesthesia 35 Classification of Anesthesia • Regional anesthesia • Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves is blocked with administration of local anesthetic 36 Classification of Anesthesia • Conscious sedation • Minimally depressed level of consciousness with maintenance of patient’s protective airway reflexes 37 Additional Anesthetic Considerations • Controlled hypotension • Decrease amount of expected blood loss by lowering blood pressure during administration of anesthesia 38 Additional Anesthetic Considerations • Hypothermia • Deliberate lowering of body temperature to decrease metabolism • Reduces demand for O2 and anesthesia 39 Catastrophic Events in the OR • Anaphylactic reactions • Manifestations may be masked by anesthesia • Vigilance and rapid intervention essential 40 Catastrophic Events in the OR • Malignant hyperthermia • Inherited hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium • Rare metabolic disease • Hypermetabolism of skeletal muscles → muscle contracture, hyperthermia, hypoxemia, lactic acidosis,cardiac collapse 41 Catastrophic Events in the OR • Malignant hyperthermia • Tachycardia • Tachypnea • Hypercarbia • Ventricular arrhythmias • Rise in body temperature NOT an early sign • Can result in cardiac arrest and death 42 43
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